Affordable Insurance
Auto~Home~Business~Life
706-297-0009
510 W. Avenue -
Gainesville
Ga
30501
affordable@negainsurance.com
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Home Quote
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Workers Comp
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Auto Quote
Home Quote
Business Quote
General Liability
Workers Comp
Business/Property Coverage
Contractor General Liability
Life Quote
Contact
Find Us
Click to Pay:
Business/Property Coverage
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Name
*
First
Last
Email
*
Phone Number:
Property Address:
*
What is the business/property being used for?
If a new purchase please provide prior or existing business address if applicable:
State & County with zip code property is located in:
Located in County or City?
Choice 4
County
City
Owner Date of Birth:
Owner Social Security #:
Relationship Status:
Spouse not associated with business
Married
Single
If Married-Spouses Name:
First
Last
If Married-Spouse Date of Birth:
If Married-Spouses Social Security #:
Occupied by:
Owner
Renter
Property is Leased to others
Past Claims?
No
Yes-Water Damage
Yes-Fire Damage
Yes-Storm Damage
How long have you owner the property?
Current Insurance Provider:
New so not applicable
State Farm
Country Insurance
Travelers
Farm Bureau
Geico
Allstate
Others
Mortgage Company or Lien on property?
Yes
No
Amount needed to rebuild structure (do not include land value):
Business structure type:
Brick Exterior
Frame with Siding
Mobile Home
Modular
Roof Condition:
Less than 5 yrs old
5-10 years old
11-15 years old
15+ years old
Bankruptcy?
No
Yes
Yes-longer than 7 yrs ago
Fire Hydrant location:
Less than 500 feet of structure
500-1000 feet of structure
1001+ feet of structure
Check all that apply:
Trampoline
ATV
Pool
Alarm System
Fireplace
Central Heating
Fire suppression system
Cooking on premise
Contact Preference:
Email
Text
Phone Call
Comment
Submit
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