W.A. George -

W.A. George Insurance Agency - Providing the Perfect Coverage Mix Since 1972

Quick Quote

General Information

Please provide the following contact information:

Name*

Title

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone*

FAX

E-mail*

URL

Please identify and describe yourself:

First Name*

Last Name*

Date of Birth

Sex Male Female

Enter the date of last building update:

-- mm/dd/yy

Please select updates done:

Electric
Plumbing
Wiring
Roof
Heating
Cooling
Other (Please explain in 'comment' box)

What is the foundation square footage of your property?

What is the total square footage of your property?

How many stories are there/will there be?

How many units are there/will there be?

Do you own the building?

Yes No

If yes, tell us the year purchased:

How old is the building, please enter the year built?

Please enter the purchase price:

If you are leasing the building, please enter the year your lease started:

Please enter the square footage of leased space, if applicable?

Annual lease payment:

Is the building vacant?

Yes No

If you answered no, please indicate the vacancy rate (average percentage of vacant units annually):

Please tell us the function of this building:

Apartments
Professional Offices
Retail Stores
Restaurants
Day Care Centers
Grocery Stores
Factory
Industrial
Other (Please explain in the 'comment' box):

Is there a sprinkler systems installed?

Yes No

Do you have a burglar alarm system?

Yes No

Enter the name of the alarm monitoring company/central station in the space provided below:

Do you have a fire alarm system?

Yes No

Enter the name of the monitoring company/central station in the space provided below:

Please indicate other items on the premises which require insurance coverage:

Property in Transit
Telephone Equipment
Office Furniture
Fine Art
Computer Equipment
Property in Storage
Jewelry
Electronics
Mechanical Equipment
Building Supplies and Equipment
Other (Please specify in the 'comment' box)

Loss Information Have you have any losses in the past three years?

Yes No

If yes, please indicate below:

Fire
Water Damage
Windstorm
Vandalism
Other

If you selected other for Loss Information, please explain here:

Comments: