Serving Massachusetts since 1983
(617)926-4000                                        Expert, friendly & helpful insurance services.    
Independent Insurance Agent

Business Insurance Information Form
Customer Information
First Name: 
Last Name: 
City:    State:    Zip: 
Day Phone:    Cell Phone: 

Business Information
Business Name: 
City:    State:    Zip: 
Description/Type of Business: 
Number of Employees: 
Number of Years in Business: 
Annual Payroll: 
Occupancy Status:  Owner  Tenant 

Property/Premises Information
Year Built:     Square ft:    %Occupied: 
Fire Sprinklers:  Yes  No 
Burglar Alarm:  Yes  No 
Construction Type: 
Number of stories: 
Basement:  Yes  No    If Yes, please select
Describe any property claims in the past 5 years: 

General Liability Information
Annual Gross Sales:     Annualized Payroll: 
Subcontract work cost (if any)
Liability Limits: 
Describe any liability claims in the past 5 years: 

Additional Comments


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Guard Insurance Agency, 279 Mount Auburn Street, Watertown Massachusetts 02472
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