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   Providing businesses and individuals

                    peace of mind

 






 

155 N. Ft. Thomas Ave.

Ft. Thomas, KY  41075

859-441-4100 phone

859-572-3056 fax

www.penderyins.com

 


Commercial Submission
 

Please complete the following submission and click 'Submit.' A representative will contact you shortly.

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Need by Date Agent

Requested Effective Date   Requested Expiration Date

 

Preferred Payment Plan  Annual  Semi-Annual Quarterly  Monthly

 

General Information

 

Owner Name

DBA              

Mailing Address

Premises Address

County 

Cell Phone Business Phone Fax

Is Your Business a Corporation  Sole Proprietor  LLC  Other

Federal ID# Social Security #

E-mail Address Date Business Started

Current Insurance Carrier Name and Address:

Policy # How Long

 

Coverages Requested

 

General Liability  Property  Auto  Inland Marine  Umbrella  Crime

Other 

Loss History in Last 3 Years:

Description of Business Operations:

 

Property Information

 

Location# Building#

Construction of Building Year Built # of Stories Total Area

Inside City Limits: Yes  No  Interest: Owner Tenant

Percent Occupied 

Building Improvements and Dates:

Type of Security System

Sprinklered? Yes  No

Amount of Building Coverage $ Amount of Contents Coverage $

 

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Location# Building#

Address, if different:

Construction of Building Year Built # of Stories Total Area

Inside City Limits: Yes  No  Interest: Owner Tenant

Percent Occupied 

Building Improvements and Dates:

Type of Security System

Sprinklered? Yes  No

Amount of Building Coverage $ Amount of Contents Coverage $

 

Coverages (apply to all buildings and locations unless otherwise noted)

 

 

 

   

To provide a quote, our insurance companies use information such as driving records, claims and credit history from consumer reporting agencies.

 

NT____ AWAY AT SCHOOL ______  WITH VEHICLE OR WITHOUT

 

 

To provide a quote, our Insurance companies use information such as driving records, claims and credit history from consumer reporting agencies.