(701) 353-7141 Eagan, MN

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General Information

Contact Name *

Email *

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Type of Business

Business Name

Mailing Address

City

State

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Fax

Current Insurance Company

Company Name

Current Insurance Coverages

Bond

Commercial Auto

Commercial Liability

Commercial Property

Liquor Liability

Directors & Officers Liability

Disability

Group Health

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Business Information

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How long in Business? (yrs)

How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

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Occupancy Status
Owner Tenant

Year Built

% Occupied

Sprinklers
Yes No

Construction Type

Stories

# Basements

Sq. Footage

Burglar Alarm
Yes No

Building Value

Contents

Other Property (specify)

Insurance Information

Business Personal Property Amount

Annual Gross Sales: (before taxes)

If Liquor Liability Required-Gross Annual Liquor Sales?

Annualized Payroll

Cost of any Subcontracted Work

Liability Limits Requested

$300,000

$500,000

$1,000,000

$2,000,000

Describe any claims you've had in the past 5 years

Additional Comments

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Fargo Insurance Agency | 4151 Knob Drive, Suite 202 | Eagan, MN 55122 | (701) 353-7141

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