LODGE
INSURANCE
QUOTE		   We would like to provide you with a free, no-obligation Lodge insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
 

General Information
Lodge Name and #:
Contact Name:
Address:
City:   State:   Zip:
Phone (Lodge):   Phone (Home):
Best Time To Call:   AM   PM
Contact Email Address:
Coverage Effective Date:   Need By:
Federal ID#:


Current Insurance Information
Company Name (not agency):
Policy Expiration Date:   Premium Amount: $
What type of coverages do you currently have:
Building value (own / lease): Contents value:
Current Deductible: RC or ACV Coins:
Year of Last Mechanical Update: Property Form:
Age of Building: Number of Stories:
Construction Type: Total Square Footage:
Square Footage You Occupy: Miles From Coast:
Miles From Fire Dept/Hydrant:  


About Your Facilities
Do you have restaurant/
kitchen facilities?: 		y   n       Annual Food Sales $
Current Membership:


Miscellaneous Information
Describe any losses in the last five years:
Any other coverages: (Employee Dishonesty, Money & Securities, Business Income, etc.)


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.


How Did You Hear About Us?
Please let us know how you found out about our agency on the internet:

Search Engine    (Type:)  
Direct Mail    
Yellow Pages    
Already a Customer    
Referral    (By:)  
Other    (Type:)  
 


Submit Information
Click Submit and a representative from Petra Insurance will contact you by:

E-mail  
Regular Mail     
Phone   Best time to call? 
Fax   Fax Number: 

   

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