Se Habla Espanol

Please fill out as much information as possible. The more fields you fill in, the better we can help you.  If you do not receive an e-mail or phone call from Al Deleon Associates, Inc. within 48 hours after submitting this form, or if you have any questions about this form, please contact us.

 

Contact Name:* Email:*
Birth Date:* (mm/dd/yyyy) Social Security or FEIN#:
Business Phone:* Best time to call:
Home Phone:*
Cell Phone:
Business Name:
Address:*
City:*
State:*
Zip:*
Fax:
Current Insurance Company
Company Name:
Expiration Date:
Years Experience 
Current Coverages or Needs
Commercial Liability
Commercial Property
Workers Compensation
PEO(Leasing Company)		 Commercial Auto
Commercial Umbrella
Bond
Retirement Program
Other
Business Information
# of FT Employees 
# of PT Employees 
# of Owners or Partners 		 Years in Business 
Years Experience 
% of work subcontracted 
Description of Operations & Clientele
Annual Sales:
Annual Payroll:
Property Information
Number of Locations:
Business Premises: Home Office Retail Storage Shop
Year Built:  Tenant Own  # of Stories:
Construction Type:  Frame  Masonry
Tot. Sq Ft: Occupied: Yes No
Burglar Alarm: Yes No Sprinklers: Yes No
Building Value (If owned): 
Contents:
Other Property:
Loss History: Yes No


If so, describe any claims:
Comments:
How were you referred to us?:



No coverage of any kind is bound or implied by submitting information via this online form:
  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
YES! I Agree


Please enter the letters below, exactly as shown. This is for anti-spam purposes.

  
Powered By ChronoForms - ChronoEngine.com

 
More Info

Accident Report Form

Print this worksheet and keep it in your glovebox to be prepared in case of an auto accident.

Home Inventory Form

Print this worksheet and take an inventory of your home before a loss occurs.