Dry Cleaners Association

Quick Quote Request

 

• To receive a quotation for coverage, fill out the form below as completely as possible. We will contact you with a quotation in a few days. Please note the importance of providing us with your phone number in case we have further questions...OR, if you don't feel like filling out the form, just call (540) 292-9222 and we can take your information over the phone.

General Information
Named Insured:
Address:
City:
State:	-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip Code:
Phone Number:
Fax Number:
Email Address:
Number of years in business:
Prior Carrier:
List all losses in the past three years:

 

Location 1 (please copy for additional locations)
Address:
City:
State:	-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Zip:
Building Construction:	------------------ Frame Masonry Metal (NC) Fire Resistant
Protection Class:	------------------ Sprinkled Burglar Alarm
Square Footage:
Age of Building:	If over 30 years, when updated?
Building Amount:	Select One ACV RC
Deductible:
Business Personal Property Amount:	Select One ACV RC
Deductible:

 

(Please Select One)
General Aggregate	1,000,000	2,000,000	4,000,000
Products Aggregate	1,000,000	2,000,000	4,000,000
Per Occurrence	500,000	1,000,000	2,000,000
Personal/ADV Injury	500,000	1,000,000	2,000,000
Medical Payments	10,000	10,000	10,000
Fire Legal Liability	300,000	500,000	1,000,000
(300,000 included)

Payroll  $

Receipts $

            

Workers Compensation

FEIN

Experience mod

                            

State	Classification & Code	# Employees	Payroll
-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY	2587 Drycleaner
-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY	8017 Store NOC
-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY	8810 Clerical
-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
-- AL AK AZ AR CA CZ CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

If corporation, officers included --- Yes No or excluded --- Yes No

If sole proprietor or partnership, sole proprietor or partners include --- Yes No or exclude --- Yes No

Employers liability limits 100/500/100 unless otherwise indicated.

 

Automobile

Quotes will be at limits and deductibles shown below unless otherwise indicated.  All quotes will include the Broad Form Automobile endorsement.

Coverage	Limit	Deductible
Liability	1,000,000	n/a
Medical Payments	5,000	n/a
Uninsured Motorist	40,000	n/a
Comprehensive	n/a	500
Collision	n/a	500

 

Year of Vehicle	Make and Model Of Vehicle	Retail, Service, Personal or Commercial	Zip Code of Garage Location	Radius of Use	Cost New	Coverages (if different from above)
-------------------- 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920		--------------------- Retail Service Personal Commercial
-------------------- 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920		--------------------- Retail Service Personal Commercial
-------------------- 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920		--------------------- Retail Service Personal Commercial
-------------------- 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920		--------------------- Retail Service Personal Commercial
-------------------- 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920		--------------------- Retail Service Personal Commercial
-------------------- 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920		--------------------- Retail Service Personal Commercial

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