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Property Loss Notice
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Lic # 0D44460

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Authorized broker for Viking Insurance, Infinity, DriveInsurance from Progressive, AIG, and Bristol West.

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Galaxy Insurance Service Inc
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Business Owner Quote

Business Owner Application
24 - 72 Hours Turnaround Time!!!

 

Galaxy Insurance Service Inc
1001 East Pacific Coast Highway Suite 107
Long Beach, CA 90806
Phone (562) 591-8901, Fax (562) 591-3901
http://www.galaxyinsurance.com/
csr@galaxyinsurance.com
CA Lic #0D44460

 

All quotes we provide are subject to underwriters' final approval.

APPLICANT INFORMATION
Bold = Required field
First Name
Last Name
Business Name / Applicant Name
Business
Indicate Program Requested
PHYSICAL ADDRESS
Street
Suite
City
Zip Code
MAILING ADDRESS
Zip Code
City
Suite
Street
Contact Name for Inspection
Contact Phone Number
NATURE OF BUSINESS
Years in Business
Hours of Operation
Days of Operation
Gross Receipts Annually Sales
Description of
Operations / Occupancy
Surrounding Exposures & Other Occupancies
Year Built
Year Electrical Update
Year Plumbing Update
Year Roof Update
Type of Roof
Inside City Limits
Yes
No
Distance to
Square Feet
Hydrant (ft)
Fire Station (mi)
Fire and Alarm Protection
Fire and Alarm Protection
Local
Central
PROPERTY
Building
Limit
Deductible
PERSONAL PROPERTY
Deductible
Limit
Number of Stories
LIABILITY
(Choose the limit options compatible with the program you are requesting.)
Liability Limits
Aggregate
Occurrence
Hired / Non-Owned Auto
PRIOR POLICY (IES) / LOSS HISTORY
Previous Carrier
Number Losses Last 3 Years
Total Losses
Description of Losses
How Many Years of Prior Coverage
What is the Effective Date of the Last Policy
Please account for all the time this business has been open without insurance and give a reason why they were uninsured:
GENERAL INFORMATION
(Please Explain All "Yes" Responses)
1.  Do / have past, present or discontinued operations involde(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc...)
Yes
No
ADDITIONAL INTEREST
Interest
Name
Street
Suite
City
Zip Code
Reference Number
Loan Number
Remarks:
Effective Date
Total Square Ft.
Construction Type
Sprinkler
Yes
No
Sublease
Yes
No
Sprinklers
Yes
No
Basement Present
Yes
No
Is It Finished
Yes
No
2.  Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?  Not applicable in MO.
Yes
No
3.  Do you own or operate any other business?
Yes
No
4.  Any other insurance with this company?  (List Policy Numbers)
Yes
No
5.  Are you involved in manufacturing, mixing, relabeling or repackaging of products?
Yes
No
6.  For retail stores, does installation, service or repair work account for more than 15% of receipts?
Yes
No
7.  Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
Yes
No
8.  Is all equipment inspected annually and well maintained?
Yes
No
Fire Extinguisher
Yes
No
Certificate Required
Yes
No
Email Address
lnk