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Business Quote
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General Info
Contact Name
*
Email
*
Business Name
*
Phone
*
Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
*
Fax
*
Current Insurance Company
Company Name
*
(not agency)
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
Check All That Apply
Other Coverages
*
Business Info
# 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 Info
Address
*
Occupancy Status
*
Owner
Tenant
Year Built
*
% Occupied
*
Sprinklers
*
Yes
No
Construction Type
*
Frame
Brick Veneer
Stucco
Metal
Concrete
# of Stories
*
# of Basements
*
Sq. Footage
*
Burglar Alarm
*
Yes
No
Building Value
*
Contents
*
Other Property
*
(specify)
Insurance Info
Other
*
Annual Gross Sales: (before taxes)
*
# of Employees
*
Annualized Payroll
*
Cost of Any Subcontracted Work
*
Limits Requested
*
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims from the past 5 years
*
Additional Comments
Disclaimer Notice
*
I Understand
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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