Commercial Insurance
Quotation Request Worksheet
Step 1 - Basic Info
Name (Corporation or Individual Name)
DBA (if any)
Business
-
Area Code
Phone Number
Cell (Optional)
-
Area Code
Phone Number
Fax (Optional)
-
Area Code
Phone Number
Email
example@example.com
Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address same as your Location Address?
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
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Step 2 - Business Info
Business Description
Experience in the business (Years)
How many years at this location?
Days open for business (select all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Business Opens at (hr:min)
Business Closes at (hr:min)
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Step 3 - Prior Insurance
Prior Insurance Carriers (add more row to input more companies)
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Step 4 - Property
Building Value ($)
Content Value ($)
Business Income (annual estimate)
Total Area
Do you have a central burglar Alarm
Yes
No
Name of the Alarm Company
Alarm Company Phone Number
-
Area Code
Phone Number
Fire Protection
No Sprinkler
Fully Sprinklered
Partially Sprinklered
Fire Extinquisher
Central Alarm
Local Alarm
CCTV
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Step 5 - Liability
Each Occurrence / General Aggregate:
1Mil/2Mil
2Mil/4Mil
Product & Completed Operation Aggregate
1Mil
2Mil
Other
Annual Gross Sales
Liquor Sales
Payroll
Number of employees (Full Time)
Number of employees (Part Time)
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Step 6 - Upload Doc & Submit
File Upload (Copy of your current policy)
Browse Files
Cancel
of
Camera (take photo of your current policy)
Submit
Print Form
Should be Empty: