Harris County Insurance

Baytown Agency
608 Rollingbrook Drive
Baytown, Texas 77521
(281) 427-6511
Pasadena Agency
825 Southmore Ave
Suite 202
Pasadena, Texas 77502
(713) 481-0700
Houston Metro Agency
4221 Telephone Road
Houston, Texas 77087
(832) 500-3666
(713) 641-1234
Houston Agency
13030 Woodforest Blvd
Suite C
Houston, Texas 77015
(832) 582-8500

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BUSINESS OWNERS INSURANCE
Quote Request Questionnaire

1
Your Name:
2
Your Phone Number:
3
Your E-Mail Address:
4
Business Name:
5
Owner Name(s):
6
Mailing Address:
7
City - St - Zip:
8
Location Address(es)-if different than above:
9
Are there any specific businesses or business locations owned or operated that will not be insured by this policy?
YES NO
10
When would you like this insurance to become effective?
(Past dates not acceptable.)
 
11
Type of Ownership:
Corporation  Partnership or Joint Venture   Sole Proprietorship (Individual)
Limited Liability Corporation
Other:  
12
Describe your business in detail including a description of goods or services provided, and if applicable, indicate what percentage of your operation is retail, wholesale or manufacturing
13
Total Annual Gross Receipts/Revenues:  
Current year (estimated) $
Previous year $
14
How long have you owned this business?
15 Is the business part of a franchise?
YES NO
16
Have there been any Property, General Liability or Products Liability losses, claims or suits within the last 3 years (even if not covered by insurance)?   If yes, please describe.
YES NO
Date  Description Total amount of loss
17 What actions, if any, have you taken to prevent similar losses:
18 Current/Prior Business Insurance Carrier:
How Long?:
19 Will this policy need to cover any Loss Payees/Mortgagees/Additional Insureds? YES NO
If yes, please list and describe each one below.
Location:
Name:
Address:
Interest:
Location:
Name:
Address:
Interest:
Location:
Name:
Address:
Interest:
20 Comments
Hit the Submit Button to send your Quote Request. We will get back to you with your free, no obligation quote as soon as possible.

AGENCY LICENSE # 3664
Copyright @ 2007 Harris County Insurance Center - All Rights Reserved
Offices in Houston, Baytown, and Pasadena Texas.
Note: As stated in our "Terms of Service" (TOS) agreement, descriptions of insurance coverage on this web site are for informational purposes only and may not apply, or be included on your policy. Please contact us to confirm coverage provided on your insurance policy or policies your are contemplating purchasing.