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Business & Employee Benefits
Personal Property & Casualty
Personal Life & Health
Business Insurance
Quote Request
Thank you for completing the Business Insurance Quote Request Form. We will be in contact with you as soon as possible.
Trade Association Membership (if applicable):
Contact Name:
BusinessName:
FEIN:
Address:
City:
County & State:
Zip / Postal Code:
Phone & Fax:
Email Address:
Website:
Tax ID:
Business Entity Type:
Individual
Corporation
LLC
Partnership
Other
Currently Insured?
Yes
No
If yes name of carrier:
Date coverage needed:
Years of industry experience:
Year business started:
Description of business operations:
Total Receipts:
Total payroll:
Amount of Subcontracted work:
If using Subcontractors do you require and keep copies of their insurance coverage on file?
N/A
Yes
No
Any Claims or Losses against the business in the last 5 years?
No
Yes
If Yes Please Describe:
Liability Limits desired:
Please select one...
$1000000/$2000000
$2000000/$4000000
Do you lease or own the space your office is in?
Please select one...
Lease
Own
If owned please list the replacement cost value:
Type of construction:
Please select one...
Frame
Brick/Masonry
Other
If other please describe:
Year built:
Alarm System:
Yes
No
Sprinkler System:
Yes
No
Smoke Detectors:
Yes
No
Value of your office equipment:
Value of the stock / inventory:
Do you use tools away from your office?
Yes
No
If yes what is the total value of your tools?
Do you have vehicles titled to or leased in the name of your company to be insured?
No
Yes
If yes list make model VIN # Deductible:
Workers Compensation:
Number of employees & total payroll:
Number of owners / officers & total payroll:
Comments:
Do not enter anything in this field:
