Gregg Stapp Insurance Services • 810 East Commonwealth • Fullerton, CA 92831  • (714) 680-6504 • stapp6@aol.com

 810 East Commonwealth • Fullerton, CA 92831
(714) 680-6504  •  Fax: (714) 680-6509  •  stapp6@aol.com
Mon-Fri 9am-5pm

Customer Satisfaction Is Our #1 Priority

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Gregg Stapp Insurance Services 
810 East Commonwealth
Fullerton, CA 92831 
 

Located in the Von Esch Law Building on the 2nd Floor

Phone: (714) 680-6504
Fax: (714) 680-6509
Email stapp6@aol.com

If you would like a Commercial Insurance Quote, please fill out the form below and click "Submit." We will get back to you as soon as possible regarding your quote.
 

Carrier
NAIC Code
Underwriter
Policies or Program Requested
Property
Glass and Sign
Accounts Receivable / Valuable Papers
Crime / Miscellaneous Crime
Transportation / Motor Truck Cargo
Equipment Floater
Installation / Builders Risk
Electronic Data Proc
Commercial General Liability
Business Auto
Truckers / Motor Carrier
Garage and Dealers
Vehicle Schedule
Boiler and Machinery
Workers Compensation
Umbrella
Untitled Item
Quote
Issue Policy
Bound
If Bound, give Date and Time
Proposed Eff Date
Proposed Exp Date
Billing Plan
Direct Bill
Agency Bill
Payment Plan
Audit
Name
Mailing Address
Untitled Item
Individual
Partnership
Corporation
Joint Venture
Subchapter 'S' Corporation
Limited Corporation
Not for Profit Org
CR Bureau Name
ID Number
Year Started
Inspection Contact
Phone
Accounting Records Contact
Phone
Loc #
Bld #
Street, City, County, State, Zip 4
City Limits
Inside
Outside
Interest
Owner
Tenant
Year Built
Part Occupied
Loc #
Bld #
Street, City, County, State, Zip 4
City Limits
Inside
Outside
Interest
Owner
Tenant
Year Built
Part Occupied
Loc #
Bld #
Street, City, County, State, Zip 4
City Limits
Inside
Outside
Interest
Owner
Tenant
Year Built
Part Occupied
Description of Operations by Premise(s)
Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?
Yes
No
Is a formal safety program in operation?
Yes
No
Any exposure to flammables, explosives, chemicals?
Yes
No
Any catastrophe exposure?
Yes
No
Any other insurance with this company or being submitted?
Yes
No
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
Yes
No
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?
Yes
No
During the last ten years, has any applicant been convicted or any degree of the crime or arson?
Yes
No
Any uncorrected fire code violations?
Yes
No
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
Yes
No
Remarks
Indicate Sections
Status of Submission
Package Policy Information
Enter this information when common dates and terms apply to several lines, or for monoline prices.
Applicant Information
(First Name Insured)
(Include Zip + 4)
Premises Information
Nature of Business
General Information
Explain all "YES" responses in the Remarks section
Not applicable in MO
(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, IN, ME, and VA, insurance benefits may also be denied).

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