Questionaire
Please complete the following form and submit to Flavin & Flavin Insurance Agency for a quote.
(This is not to be considered a binder or insurance coverage) .

Company name:

Address 

City     State       Zip Code

Phone number: Fax number:  Email:     

Type of Insurance desired:

Select below: Home Auto Dwelling Business Flood Liability Contractors Workers Comp. Bond Commercial Property

Location:

Is it the Primary Location?:

 Yes               No

Amount coverage desired:

Age of Property:

Select below: 0 - 1 years 2 - 5 years 6 -10 years 11 - 15 years 16 - 20 years 21 - 30 years 30 - 50 years 51 - 75 years 76 - 100 years over 100 years

Type of Construction:

Select below: Wood Frame Joisted Masonry Fire Resisted Brick Veneer Concrete

Square Feet:

Select below: under 1000 sqft. 1000 - 2000 sqft. 2000 - 3000 sqft. over 3000 sqft. I am not sure

Number of Families:

Select below: single 2-family 3-family 4-family more than 4 family Commercial building

Type of Business:

Select below: Office Commercial Apartments Other

How long in Business:

Select below: 0 - 1 years 2 - 5 years 6 -10 years 11 - 15 years 16 - 20 years 21 - 30 years 30 - 50 years 51 - 75 years 76 - 100 years over 100 years

Any updates to the roof, plumbing, heating or electrical systems, etc. recently:

 Yes            No

If YES, please describe:

Any Prior Losses:

 Yes                  No

If YES, please describe:

Additional information may be  necessary for a final quote. 
A representative of Flavin & Flavin will contact you.

THANKS you for your request for a quote. (This  is not to be considered a binder or insurance coverage).