Robert C Benner Insurance, LLC.

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General Information
Contact Name*:
Email*:
Business Name:
Address:
City:
State:
Zip:
County:
Business Phone:
Fax:
Current Insurance Company
Company Name:
Policy Expiration Date:
Current Insurance Coverages
Current Coverages:
Business Information
# of Full-Time Employees:
# of Part-Time Employees:
Years in Business:
# of Locations:
A brief description of your business and clientele:
Property/Premise Information
Address:
Occupancy Status: Owner
Tenant
Year Built:
% Occupied:
Sprinklers: Yes
No
ConstructionType:
Stories:
# Basements:
Sq. Footage:
Burglar Alarm: Yes
No
Building Value:
Contents:
Other Property (please specify):
Insurance Information
Current Company:
Annual Gross Sales (before taxes):
# Employees:
Annualized Payroll:
Cost of any Subcontracted Work:
Limits Requested: $300,000
$500,000
$1,000,000
$2,000,000
Describe any claims in the last 5 years:
Additional Comments:
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