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Gas Station & Convenience Store Form
Free Premium Estimate Questionnaire (Non-Binding) Indication of Coverage

Download PDF Click here for a PDF version.
Complete the pdf form and fax it to (562) 928-8149.

Please answer all questions for a non-binding Premium Estimate.

Gas Station & Convenience Store
Insurance Questionnaire Form

Name insured: *
Mailing address: *
City: *
State: *
Zip code: *
Location address: *
City: *
State: *
Zip code: *
Contact name: *
Telephone: *
Email: *
Franchise name:
Years in business: *
Years at this location: *
Current insurance company: *
Current insurance company expiration date: / / *
Hours of operation: *
Federal tax id#: -
Liquor sales: $ *
Mini mart sales: $ *
Car wash sales: $
Gallons of gasoline sold: *
General auto repair sales: $ *
Number of employees: *
Payroll: *
Propane sales: $ *
Building square footage:
Building age:
Sprinklered? Yes No
Alarm? Yes No
Security camaras? Yes No
ATM machines? Yes No
If yes, are they located inside or outside? Inside Outside

Coverage Limits Requested (Please Give Amounts)
Building: $
Contents: $
Canopy: $
Gasoline in Ground: $
Car wash equipment: $
Hozes & nozzles: $
Pumps: $
Liability limits: $
Liquor liability: $

Please provide loss history in writing from your insurance companies covering the past four years. We need this to provide the best possible pricing. Loss history called "loos runs" are neeeded to quote workers compensation and business owners packages.

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