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Lehman Insurance Agency
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Contact Information
Name of Business:
Contact Name:
Premises Address:
City:
State: Zip:
Business Phone:
Fax Number:
Contact Email Address:
Years in Business:
Description of Operations
or SIC code(s):

Current Insurance Information
Current Insurance Carrier:
Premium: $ Expiration Date:
Annual Sales: $ Payroll: $ Business Income: $
Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years: Amount paid for each loss: $
Description of losses or loss runs:
Coverage's Desired
Liability Limit Desired: Deductible Desired:
Or choose other liability limit amount: $
Umbrella Amount Desired:
Building 1
Building Value: $ Contents Value: $
Total Building Area: Year Built:
Construction Type: Sprinklers:
Electrical Type: Amps:
Electrical Renovation Year:
Plumbing Renovation: Plumbing Renovation Year:
Heating Type: Heating Renovation Year:
Roofing Renovation: Roof Age (years):
Central Alarm:

List Neighboring Businesses:
To the right: Distance:
To the left: Distance:
To the rear: Distance:
Building 2
Building Value: $ Contents Value: $
Total Building Area: Year Built:
Construction Type: Sprinklers:
Electrical Type: Amps:
Electrical Renovation Year:
Plumbing Renovation: Plumbing Renovation Year:
Heating Type: Heating Renovation Year:
Roofing Renovation: Roof Age (years):
Central Alarm:

List Neighboring Businesses:
To the right: Distance:
To the left: Distance:
To the rear: Distance:
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
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