Business Quote – Maverick Insurance

General Info

Contact Name*

Email*

Business Name*

Phone*

Address*

Address Line 2

City*

State*

Zip Code*

Fax*

Current Insurance Company

Company Name*

(not agency)

Date*

Current Insurance Coverages

Current Coverages*

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*

Year Built*

% Occupied*

Sprinklers*

Construction Type*

# of Stories*

# of Basements*

Sq. Footage*

Burglar Alarm*

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*

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.