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Business Insurance - Quote Request
Business Information
Contact Name:
*
First
Last
Contact's Title/Position:
Phone #:
*
Email:
Legal Name of Business:
*
Is business done under a different name?
No
Yes
If yes, what name are you doing business as?
Business Address:
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Is business address same as mailing address?
Yes
No
If no, what is mailing address?
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Please provide description of business operations:
How many owners are there?
How many employees are there?
What is the annual payroll amount (excluding owners)?
What are the gross annual sales?
Are subcontractors used?
No
Yes
Are any autos used for the business?
No
Yes
Subcontractor Information
What was total cost for subcontractor use last year?
Please list and describe subcontractor use:
Is there a subcontractor agreement, and a copy available?
Yes
No
Building Information
Year Built:
Total square footage of property:
How many stories?
Construction Type:
Brick on Frame
Frame (Siding)
Brick
Stucco
Stone
Foundation Type:
Slab
Crawl Space
Unfinished Basement
Finished Basement
Walkout Basement
Type of Roof:
Asphault
Asphault - 3 Dimensional/Architectural
Slate
Metal
Year Roof Last Replaced/Updated:
Are there Circuit Breakers?
Yes
No
Year Electric Last Replaced/Updated?
Heating System:
Natural Gas
Propane
Oil
Electric
Year HVAC Last Replaced/Updated:
Is HVAC on roof?
Yes
No
How many HVAC units?
Year Plumbing Last Replaced/Updated?
Garage Type:
None
Attached - 1 Car
Attached - 2 Car
Detached - 1 Car
Detached - 2 Car
Do you have any other detached structures?
No
Yes
If yes, please list and describe:
Is there an alarm system that notifies the police and fire department?
No
Yes
Is there a fire sprinkler system in the building?
No
Yes
Who is responsible for Betterments & Improvements?
Auto Information
Are there any non-owned vehicles used in the business?
No
Yes
Are any business vehicles also used for personal use?
No
Yes
Third Choice
Are any business vehicless not titled in the business name?
No
Yes
Please enter all vehicle(s) information: year, make, model, and VIN #:
Insurance Status
Do you currently have Commercial Insurance?
Yes
No
Current Insurance Information
Current Insurance Carrier?
What is the Policy #?
What is the expiration date of the current policy?
MM
DD
YYYY
Were there any claims or losses in the last 5 years?
No
Yes
If yes, what is the date, amount paid and description of each loss or claim?
Are Loss Runs available?
Yes
No
Building Coverage:
Business Personal Property Coverage:
Computer Coverage:
Business Income Coverage:
You can enter "Actual Loss Sustained" or a specific number
General Liability Coverage/Aggregate:
Medical Payments Coverage:
Employment Practices Liability Insurance Coverage:
Do you currently have an Umbrella Policy?
No
Yes
Additional Information
Additional Questions or Comments:
Additional Documents/Related:
Optional - Please attach any related documents that may further help to provide an accurate quote (such as current policy declaration pages)
How did you hear of us? (If referred, please list name)
Please note:
Insurance coverage cannot be bound without a written binder from our office.
Additionally, many insurance carriers use information gathered from you and outside sources about your claims, driving, and credit history. This information allows insurance companies to determine accurately the proper premium to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.
By filling out this quote you agree to the above terms.
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