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Commercial Insurance Quote
General Information
Contact Name *
Email *
Business Name
Address
City
State
Zip
Country
Business Phone
Business Fax
Current Insurance Company
( not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
Bond
Disability
Commercial Auto
Group Health
Commercial Liability
Group Life
Commercial Property
Professional Liability
Commercial Umbrella
Worker's Compensation Other
Directors & Officers Liability
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
Frame
Brick Veneer
Stucco
Metal
Concrete
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
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.
