business insurance

Business Insurance Quote


General Information


  * indicates required fields
  Contact Name *
  Date of Birth
  Email *
  Business Name
  Address
  City
  State
  Zip
  County
  Business Phone
  Fax


Current Insurance Company



  (not agency)
  Company Name
  Policy Expiration Date


Current Insurance Coverages



  CurrentCoverages Bond

Commercial Auto

Commercial Liability

Commercial Property

Commercial Umbrella

Directors & Officers Liability

Disability

Group Health

Group Life

Professional Liability

Workers' Compensation

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 Information



  Address
  Occupancy Status Owner  Tenant
  Year Built
  % Occupied
  Sprinklers Yes  No
  Construction Type
  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