If you're interested in receiving more information about our agency, or if you have questions regarding other insurance products, please be sure to call or e-mail us.

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

Gregg Stapp Insurance Services
CA License #0806917

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
Indicate Sections
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   
Status of Submission

Quote    Issue Policy    Bound   
If Bound, give Date and Time
Package Policy Information
Enter this information when common dates and terms apply to several lines, or for monoline prices.
Proposed Eff Date
 Proposed Exp Date
Billing Plan
Direct Bill    Agency Bill   
Payment Plan
 Audit
Applicant Information
Name
(First Name Insured)
 Mailing Address
(Include Zip + 4)

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
Premises Information
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
Nature of Business
Description of Operations by Premise(s)
General Information
Explain all "YES" responses in the Remarks section
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?
Not applicable in MO
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?
(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).
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
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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