Hylant Group - Insurance Solutions, Risk Management, Consulting

Hylant Group of Ann Arbor - Kilwins Insurance Application	«« Back to Hylant Group Resources

If you would prefer to speak with an Agent instead of completing this online form, please call Hylant Group of Ann Arbor at 734-741-0044. All fields are required for an accurate quote otherwise an agent will need to contact you for additional information. Thank you!

General Information

Business Name:	Contact Person:
Address #1:	Address #2:
City:	State:	Zip:
Daytime Phone:	Evening Phone:
Fax:	E-mail Address:

Premises Information

Location Number

Building Number

Street, City, County, State, Zip

Years in Business:		Do you own or rent your location?
Annual Sales

Workers' Compensation

EIN Number:		Number of Full Time Employees:
Number of Part Time Employees:		Payroll 8810 (Clerical)
Payroll 8017 (Store-Retail):

Building Information

Construction:

Year Built:

Square Feet:

Number of Stories:

Percent Occupied:

Sprinklered

Updates:

Heat

Plumbing

Electricity

Roof

Limits

Building Value:

Contents Value:

Prior Carrier Information

Prior Carrier:		Losses in last 5 years?
If yes, please provide details:

Current Premium:		Package:

Please note that no coverage can be bound, changed, or deleted via this web site. You may make a request.
However, any request is not deemed effective until a formal verification is sent to you from our office.

Hylant Group of Ann Arbor - Kilwins Insurance Application