Cameron County Insurance Center    
    DBA Coleman Hall and Heinze
Port Isabel Office
302 E. Queen Isabella Blvd
Port Isabel, Texas 78578
Phone (956) 943-6481
Fax (956) 943-7086
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BUSINESS OWNERS INSURANCE
Quote Request Questionnaire

1
 Your Name:
2
 Your Phone Number:
3
 Your E-Mail Address:
4
 Business Name:
5
 Owner Name(s):
6
 Mailing Address:
7
 City - St - Zip:
8
 Location Address(es)-if different than above:
9
Are there any specific businesses or business locations owned or operated that will not be insured by this policy?
YES NO
10
 When would you like this insurance to become effective?
(Past dates not acceptable.)  
11
 Type of Ownership:
Corporation  Partnership or Joint Venture   Sole Proprietorship (Individual)
Limited Liability Corporation
Other:  
12
 Describe your business in detail including a description of goods or services provided, and if applicable, indicate what percentage of your operation is retail, wholesale or manufacturing
13
 Total Annual Gross Receipts/Revenues:  
Current year (estimated) $
Previous year $
14
 How long have you owned this business?
15 Is the business part of a franchise?
YES NO
16
Have there been any Property, General Liability or Products Liability losses, claims or suits within the last 3 years (even if not covered by insurance)?   If yes, please describe.
YES NO
Date  Description Total amount of loss
17 What actions, if any, have you taken to prevent similar losses:
18 Current/Prior Business Insurance Carrier:
How Long?:
19 Will this policy need to cover any Loss Payees/Mortgagees/Additional Insureds? YES NO
If yes, please list and describe each one below.
Location:
Name:
Address:
Interest:
Location:
Name:
Address:
Interest:
Location:
Name:
Address:
Interest:
20 Comments
Hit the Submit Button to send your Quote Request. We will get back to you with your free, no obligation quote as soon as possible.

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Copyright @ 2007 Coleman Hall and Heinze Insurance - All Rights Reserved
Serving Cameron County Texas, The Texas Gulf Coast, Port Isabel, Brownsville, Harlengin, McAllen, Edinburg, Kingsville, Laguna Vista, San Benito, and South Padre Island, Texas.
Note: As stated in our "Terms of Service" (TOS) agreement, descriptions of insurance coverage on this web site are for informational purposes only and may not apply, or be included on your policy. Please contact us to confirm coverage provided on your insurance policy or policies your are contemplating purchasing.