Commercial Insurance Quote Data

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. 

 

General Information

Company or Name

Contact

Address

City

   

State

Zip

Phone

     Ext

Alternate Phone

 Ext

Fax

Email

Respond back by
Phone Fax Email All

Effective Date Requested

 Month Day

Fein or S.S.#

Business Experience

Years Experience
  Year Started Business

Entity Type

Individual    Corporation Chapter S Corp
Not for profitPartnership Joint Venture
Limited Corporation

Nature of Business

General Liability
Please provide us the desired limits you are looking for. If you do not know we will call you:

Liability

Professional Liability

Products/Completed opps Liability

Property rented

Medical Expenses

Deductible

Payroll

 (minimum 15,000)

Sales
Property Coverage

This will give us a basic idea of what you are looking for. We will call or email you for more information if we need it. We will rate all on a replacement cost assuming a 90% coinsurance value.

Deductible

Property

Betterments

Business income

Other Coverage

Amount

Premise Information
Location 1
Street
City
County
Zip code
City Limits Inside Outside
Ownership Interest Own Rent
Year Built
Square Footage
Part Occupied
Construction Type
Roof Type
Monitored Alarm Y N

Location 2
Street
City
County
Zip code
City Limits Inside Outside
Ownership Interest Own Rent
Year Built
Square Footage
Part Occupied
Construction Type
Roof Type
Monitored Alarm Y N

Additional Locations

 Enter the information requested above for any additional locations below:

Rating Information
(Explain all yes answers in remarks below)
Are you a subsidiary of another entity Y N
Do you have a formal safety program Y N
Any Exposures to Flammables, Explosives, Chemicals? Y N
Any Catastrophic Exposures? Y N
Any policy or coverage declined, cancelled or non-renewed in past 3 years? Y N
Any past losses due to sexual abuse or molestation allegations, discrimination, negligent hiring? Y N
During the past 10 years, has any applicant been convicted of any degree of the crime of arson? Y N
Any bankruptcies, tax or credit liens against the applicant in the past 5 years? Y N
Remarks for all yes answers:
Additional Comments or requests:

   
 

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