El Dorado Insurance Agency, Inc.: Fire Extinguisher/Suppression Liability Questionnaire

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Fire Extinguisher/Suppression Liability Questionnaire

Please complete the entire form below to receive a quotation for El Dorado's custom tailored Fire Extinguisher/Suppression Liability Coverage. Use the "tab" key or your mouse (not the "return" key) to easily navigate between the fields. Your information will be sent to a secure server and will be held in complete confidence.

One of our specialists will contact you as quickly as possible with your final estimate.

Your Information:

Name

Mailing Address

Title

City, State, Zip

Company Name

Fax

Physical Address

Telephone

City, State, Zip

EMail (required)

Estimated Annual Revenues

$

Estimated Extinguisher Tech Payroll

$

Estimated Suppression Tech Payroll

$

Systems Are:

% Wet Sprinklers

% Dry Chemical

% Wet Chemical

% Hand Held

% Personal Safety Equipment (First Aid Kits, Gloves, etc.)

Other
(Please Describe)

Current Coverage:
Current Liability Carrier:
Current Liability Limits:
Prior 3 Year Loss History:
Do you carry Worker's Compensation?	Yes No
If so, what is your expiration date?
If not, would you like a quote?	Yes No

Please Add Any Comments or Questions Below:

Check this box before sending (required)

Thank You! A Specialist Will Contact You Shortly.

800.221.3386 • 713.521.9251
Fax 800.700.0126 • 713.521.0125
2515 North Blvd. • Houston, Texas 77098