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Business & Employee Benefits
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MERA
Business Insurance Quote Request
Thank you for completing the MERA business insurance quote request form. We will be in contact with you as soon as possible.
Are you a MERA member?
Yes
No
Contact Name:
BusinessName:
Address:
City:
County & State:
Zip 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:
Any Claims or Losses against the business in the last 5 years?
No
Yes
If Yes Please Describe:
Liability Limits desired:
Please select one...
$1 million/$2 million
$1 million/$3 million
$2 million/$4 million
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:
Number of bays:
Please select one...
0
1
2
3
4
5
6
7
8
9
10 or more
Garage Keepers Limit:
Do you have vehicles titled to or leased in the name of your company to be insured?
No
Yes
If yes list: (1) Year (2) Make (3) Model (4) VIN # (5) Comprehensive Deductible (6) Collision Deductible (7) Radius driven from shop:
Workers Compensation:
Number of employees & total gross payroll:
Employee Classifications & Descriptions:
Comments:
Do not enter anything in this field:
