October 20, 2017
Coming Soon!

Business Quote

General Information
Contact Name *
Email *

Business Name
Address
City
State
Zip
Website
Business Phone
Fax
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
Check the Coverages That You Presently Carry Bond
Commercial Auto
Commercial General Liability
Commercial Property
Commercial Umbrella
Contingent Auto Liability
Contingent Cargo Liability
Directors & Officers Liability
Disability
Equipment Floater
Garage Liability
Garagekeepers Liability
Group Health
Group Life
Professional Liability
Tool Floater
Workers' Compensation
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and what we can help you with
Property/Premises Information
Address
Occupancy Status Owner  Tenant
Year Built
% Occupied By You
Sprinklers Yes  No
If Yes to Sprinklers Wet System  Dry System
Construction Type
Stories
# Basements
Total Sq. Footage of the Premisis
Burglar Alarm Yes  No
If Yes to Burglar Alarm Local  Central Station
Building Value
Value of Your Contents
Other Property (specify) or Locations
Insurance Information
Other
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Liability Limits Requested $300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.