Emery & Webb Insurance for the Music Industry

(800) 942-5818

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Insurance Quote for Music Store Owners

The information requested on this form will allow us to request a premium indication from multiple insurance carriers on your behalf. Should you choose to accept one of these quotes, a formal application with your signature will need to be completed.

Full Legal Name of Business*
Business Entity*
- LLC
- Sole Proprietor
- Partnership
- Corporation
- DBA
Federal ID Number
Your Name
First Last
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is the location address the same as the mailing address?
- Yes / Not applicable
- No, it is different
Location Address
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Email*
Date Your Current Business Started
MM slash DD slash YYYY

If you don't know the exact day, use the 1st of the month in the proper year.
Date quote is needed by?
MM slash DD slash YYYY
Do you have a current business insurance policy?
- Yes
- No
Current Insurance Information
Current Business Owner's Insurance Carrier
Current Insurance Premium
Expiration Date of Current Policy
MM slash DD slash YYYY
Have you had any losses or claims in the last 5 years on your business policy?
- Yes
- No
If yes, please give a description of the loss, the date of the loss, the amount paid and whether the claim is now open or closed.*
Property Information
Do you own the building or lease/rent the office space?
- Own the building
- Lease / Rent the space
What is the building value?

How much is it insured for on your current policy?
Year Built
Square Footage of Building
Square Footage You Occupy
Number of Stories
Are there other occupant businesses? Please list them below
Construction Type
- Masonry
- Frame
- Masonry with wood joists
Year of most recent updates to the:
Roof
Heating
Electrical
Plumbing
Type of Heat

If boiler, please describe and give age.
Is the building 100% sprinklered?
- Yes
- No
Is there a burglar alarm?*
Is there a fire alarm?*
Store Information
Value of business personal property

i.e. equipment, office furniture, supplies, computers
Value of retail stock
Annual Gross Sales
% of business from rentals
% of business from repairs
% of business from lessons
% of business from internet sales
Max value of items being shipped at any given time
How are items shipped
Deductible on current policy
Do you have a mortgage on the building or a loss payee on the business or business equipment?
If so, please give full name and address
Are there any other additional insureds that should be listed? (i.e. landlord)

If so, whom?

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