Commercial Insurance Quote
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Insured
Information
* Required Field
General Information
Contact Name
*
Email
*
Business
Name
*
Street Address (Not
PO Box)
*
City
*
State
*
County
*
Zip
*
Business
Phone
*
Fax
Current Insurance Company
Company Name
Policy Expiration Date
Current Insurance Coverage
Current
Coverage
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
*
Only fill this portion if you need property coverage. If No property
coverage is required skip to next Section
Property/Premises
Information
Address
to be insured
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Stories
# Basements
Sq. Footage Occupied
Burglar Alarm
Yes
No
Building Value
Contents
Other Property
(specify)
Limits Requested
Annual Gross Sales: (before taxes)
*
Annual Payroll
*
Percent of work Subcontracted
*
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,
information. You
may also ask questions in this box.
Disclaimer Notice - The
premiums quoted are estimates based on information you provided. If you have
question or other pertinent information you feel is necessary to properly
quote your Insurance, Please feel free to call our office for a personalized
free quote.
