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  

  CurrentCoverages

Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
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

  Other Property (specify)

 

 Insurance Information  

  Other

  Annual Gross Sales: (before taxes)

  Number of Employees

  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.