Business Quote

General Information

Contact Name *
Email *

Business Name
Address
City
State
Zip
County
Business Phone
Fax

Current Insurance Company

(not agency)

Company Name
Policy Expiration Date

Current Insurance Coverages

Current Coverages

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/Premises 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

* indicates required fields

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.