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Business & Commercial Insurance Quote First & Last Name:   Business Name:   Street Address:   City, State & Zip:   E-Mail Address:   Telephone:   Fax:   Current Insurance Information Insurance Company Name:   Any Losses in last 3 yrs?:   Premium Amount:   Policy Exp. Date:   Describe the Type of Coverage you Currently have:    About Your Business # of Full-time # of Part-time Yrs. in Business # of Locations: Yr. building built Sprinklered? Annual Gross Sales Square Footage? Yes No Building Type:   Masonry Framed Type of Business:   Please select Wholesaler Retailer Manufacturer Contractor Apartment Service Owned Autos:   Est. payroll / mo.:   Please describe your business here:

106 S. Penn Oberlin, Ks 67749 Tel: (785) 475-3310 Fax: (785) 475-8965 117 N. Kansas Norton, KS 67654 Toll Free: 866-484-6236 Tel: 785-877-4016 Fax: 785-874-4832 PO Box 235 101 Front St. Winona, KS 67764 Tel: (785) 846-7476 Fax: (785) 846-7479