Manufacturer/Distributor

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Manufacturer/Distributor

This is only a request for quotation! No insurance will be bound by completion of this application.

First Name: (*)

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Last Name: (*)

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E-Mail Address: (*)

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Phone: (*)

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Business Information

Business Name:

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Street Address:

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City:

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State:

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Zip:

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Phone:

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How did you locate our agency?

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Please describe your business operations:

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Ownership Type:

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If Partnership, Partner Name:

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How many years experience?:

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Are you an Association member?

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Current Insurance Carrier Name:

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Date Current Policy Expires:

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Any losses or claims in the current or last 3 policy periods?

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If yes, approximate number of claims?

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If yes, total $ amount of claims

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Estimated Annual Receipts:

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Estimated Annual Payroll:

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Number of Employees:

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Number of (IC) Independent Contractors

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Building Description

Type of construction:

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Does your building have sprinklers?

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Is your business located in your home?

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If you answered yes to the previous question,
is your business in a separate building on your property?

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Are you the owner or tenant?:

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Cost to replace building (if owner)
(Does not apply if your business is operated from inside of house):

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Cost to replace your contents (clippers, cages, loose items, etc.)
(Include value of pets for sale - if applicable):

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Total square footage of your building (owner):

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Total square footage of your shop:

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Year building built:

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If building is more than 25 years old, please list approx. years of updates

Heating

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Cooling

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Plumbing

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Roofing

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Electrical

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Please write any comments, questions
or additional information.

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Email Us

Governor Insurance Agency
P.O. Box 770
972 Youngstown-Kingsville Rd. SE
Vienna, Ohio 44473

Phone:
330-539-9999
330-448-4321
330-394-1805

Fax:
330-539-9998
888-539-0524

Phone:
330-539-9999
330-448-4321
330-394-1805

Fax:
330-539-9998
888-539-0524

Toll Free:
800-843-5522
877-738-4766 (PET GROOMER)
866-536-6354 (KENNEL INS)

(330) 539-9999