Fast-teks® Insurance
Quote Form

The information below is to facilitate receiving an insurance quote.
After submitting this form, an A&R representative will contact you to discuss
information which will provide you with an accurate quote. You understand
that there is no coverage in force until an application is approved.

GENERAL INFORMATION

Business Name

Doing Business As

Mailing Address

City
, State Zip
Phone
Extension
Fax

Email

Effective Date Desired

Years of Experience in Field

INSURANCE QUESTIONS

Number of years in Business (If new, skip to question "estimated gross annual receipts" below)

Current Insurance: General Liability, Carrier, Expiration Date

Current Insurance: E&O Liability, Carrier, Expiration Date

Current Insurance: Workers Compensation, Carrier, Expiration Date

Any claims, suits, demands or circumstances that might be source of future claim against your
franchise in the past 5 years? If yes, detailed information will be requested

Estimated gross annual receipts (if new – projected first year receipts)

Does the franchise own any business property to be insured?
Yes No If Yes value $

Estimated number of employees and Payrolls
Techs # Estimated Annual Payroll of Techs $
Office/Clerical # Estimated Annual Payroll Office/Clerical $
Salesperson(s) (other than owner) # Estimated Annual Payroll Salesperson(s) $

 

OPERATION QUESTIONS

Percentage of Revenue generated from Residential Customers
Percentage of Revenue generated from Commercial Customers

Indicate which of the following Products/Services offered to your clients:
(selcet all that apply)

Application Service Provider (ASP) Services
Consulting Services
Custom Programming Services
Information Security Services
Installation/Integration/Maintenance of Hardware Products Manufactured by others
Data Backup and Recovery
Internet Search Engine & Portal Services
IT Network and Systems Management / Systems Outsourcing
Software/Hardware Training
Manufacturing of Hardware Products/Components
Packaged Software Development and Sales (including related installation, support and maintenance)
Resale of Hardware Products Manufactured by Others
Software Installation/Integration/Maintenance of Software Products of Others
Telecommunication Services
Web Site Design
Other (please provide clear description)

THIS INFORMATION IS BEING SUBMITTED WITH THE EXPRESSED INTENT OF SECURING A QUOTE FOR INSURANCE FOR FAST-TEKS ON-SITE COMPUTER FRANCHISES.

ALL INFORMATION IS KEPT CONFIDENTIAL

Submitted by:

Name, Title, Date

Comments

By checking this box you certify that the statements made on this quote request are accurate to the best of your knowledge