In-Home Business Insurance Inquiry
Insurance for your home based business......
PENNSYLVANIA
Please complete the information below for a no obligation quote....
Company Name:
Contact Person:
Address:
City, St., Zip:
Phone Number:
E-Mail Address:
Type:
What does your business do?
Dwelling Construction: Frame Masonary County:
Your interest in Premises:
Own or Rent
Occupancy: Single or Multiple
Year Started: Annual Sales:$ Payroll:$
Coverages....
Business Personal Property: (100% Replacement Cost)
$
Liability Limit:
Computer Hardware & Software: (optional)
$
Money & Securities:
Additional Insured/Loss Payee Information
Additional Insured.....
Controlling Interest in this business
Co-Owner of Insured Premises
Manager or Lessor of Premises
Lessor of Leased Equipment
Owner or Lessor of Leased Land
Grantor of Franchise
State/Political Subdivision
(for permits relating to the premises)
Name:
Address:
City:
State:
Zipcode:
Loss Payee
Name:
Address:
City:
State:
Zipcode:
General Underwriting Information..
Are you a professional entertainer or athlete, media personality, or state or federal political figure? Yes / No
Have you had more than two claims of any type, related to your business operation, in the past three years? Yes / No
Have you had a single claim, related to your business, for more than $25,000 in the last three years? Yes / No
Do you own any business under the same legal name as the "Business Name" shown, which is operated at a different location? Yes / No
Do you directly import any foreign products (excluding costume jewelry)? Yes / No
Do you repackage food or personal care products to be sold under your own label? Yes / No
Is your business operated in or from a mobile home or trailer? Yes / No
Are you involved in the sale or manufacturing of explosives or propellants? Yes / No
Is any single item of merchandise you sell (excluding real estate) directly valued in excess of $2,500? Yes / No
Do you install any products, excluding the installation of computer systems, office equipment, security devices or draperies? Yes / No
Is your business office based in an area other than your residence (residence includes outbuildings within 100ft)? Yes / No
Is your business operated by someone other than yourself and/or another immediate family member who resides in your household? Yes / No
Is you total dwelling area more than 7,500sq ft (include basement, garages, and outbuildings? Yes / No
Is the total area used for business 50% or more than the total area of your residence? Yes / No
Did your gross annual sales/receipts from your business pursuits for the most recent calendar year exceed $200,000 for sale of merchandise or $500,000 for a service business? Yes / No
Do you employ more than three (3) employees, other than independent contractors or distributors? Yes / No
Is your dwelling located within 1,500 feet of salt water in a coastal county on the Gulf of Mexico? Yes / No
If you are a financial planner, do you have discretionary trading authority and/or access to customers' funds? Yes / No
If you are involved in telemarketing or telephone solicitation, do you have more than three (3) phone lines? Yes / No
If you are a computer consultant, do you do custom computer programming? Yes / No
If you are a teacher or tutor, do you provide instruction for sports, physical education, industrial arts, or martial arts? Yes / No
M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway      Murrysville, PA. 15668-1890
(724) 327-8474        (FAX) 327-7911
Toll Free: 1-800-977-2999      (FAX) 1-888-800-0034