Business Quote

General Information
Contact Name *
How did you hear about us?
Business Name
Address
City
State
Zip
County
Business Phone
Email *
Website
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Annual Premium
Current Insurance Coverages
Desired Coverages Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Professional Liability
Workers' Compensation
Bond
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
Property/Premises Information
Address
Occupancy Status Owner  Tenant
Year Built
Sprinklers Yes  No
Construction Type
Stories
Basement Finished  Not Finished  No Basement
Sq. Footage
Burglar Alarm Yes  No
Building Value
Contents
Insurance Information
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested $1,000,000
$2,000,000
$300,000
$500,000
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.
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