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Amerimex Insurance
240 S Sheridan Blvd
Denver, CO 80226

Phone:
(303) 462 1410
Fax:
(303) 462 1446
E-mail: george@amerimexonline.com

   

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General Information
Company/Business Name:*
Business Address:
City: State:
Zip: Country: United States
Phone: Fax (Optional):
 
Contact Person Information
First Name: *
Last Name:
 
Day Phone: Night Phone:
Best Time To Call (HH:MM):    
E-mail Address: *
 
 
Please Tell Us About Your Business
Number of Full Time Employees: Number of Part Time Employees:
Number of Years in Business: Number of Business Locations:
Type of Business:
Annual Gross Sales (Before Tax) ($): Cost of Any Sub Contracted Work ($):
Please give a brief description of your business & clientele:
 
Location 1 Information
Address:
City: State:
Zip: Country: United States
Year Built In: % Occupied:
Building Value ($): Contents ($):
Type of Ownership:    
Construction Type:
Number of Basements: Area (Sq. Feet):
Burglar Alarm:       Sprinklers:      
 
Location 2 Information
Address:
City: State:
Zip: Country: United States
Year Built In: % Occupied:
Building Value ($): Contents ($):
Type of Ownership:      
Construction Type:
Number of Basements: Area (Sq. Feet):
Burglar Alarm:       Sprinklers:      
 
Current Insurance Information
Insurance Company Name:
Policy Expiry Date (MM/DD/YYYY): Premium Amount ($):
Any Losses In Last 3 Years?       Same Company Policy Since?
 
Please Provide An Approximate Amount For The Type Of Coverage You Want
Choose The Type of Coverage You Are Looking For:
Liability Coverage (Ex. $300,000, $500,000, $1 Million, etc.): Building Coverage ($):
Business Content Coverage ($): Miscellaneous Coverage ($) (All Coverage including Loss of Earnings, Valuable Papers, etc.):
Any additional comments or information that might be helpful in your Business Owners insurance quote:
 
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