Business Quote Form

 General Information
  Contact Name *
  Email *
  Business Name
  Address
  City
  State
  Zip
  County
  Business Phone
  Fax
 Current Insurance Company
(not agency)
  Company Name
  Policy Expiration Date
 Current Insurance Coverages
  Current Coverages Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
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 clientele
 Property/Premises Information
  Address
  Occupancy Status Owner Tenant
  Year Built
  % Occupied
  Sprinklers Yes No
  Construction Type
  Stories
  # Basements
  Sq. Footage
  Burglar Alarm Yes No
  Building Value
  Contents Value
  Other Property (specify)
 Insurance Information
  Other
  Annual Gross Sales: (before taxes)
  Annualized Payroll
  Cost of any Subcontracted Work
  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

  * indicates required fields
 
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.