Business Insurance Quote Form

1
PEOPLE'S INSURANCE CHOICE, LLCHELPING BUSINESS GAIN BETTER SOLUTIONS
2

Client Information
3
Owner's Name
4
Title
5
Email
6
Phone
7

Business Information
8
Business Name
9
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
Phone Number
11
Webpage
12
FEIN/TAX ID Number
13
Company Size
Please Select
Please Select
1-10 Employees
10-50 Employees
50-100 Employees
over 100 employees
14
Type of Business
15
Years of Experience
16
Annual Sales for the Business
17
Business Information AttachmentProof of Incorporation/ Prior Insurance/ Licensing
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
Cancelof
18
List Any Additional Location Address:
19
Have you ever had an insurance policy non-renewal, cancelled, or declined? Yes or No
20
Have you ever been convicted of a crime of fraud, bribery, or arson?Yes or No
21
Any bankruptcies, tax or credit liens? If Yes, Explain
22
Are there any additional insured's?co-ownerships or companies request certificates
23

coverages
24
Select desired coverage's below
General Liability Coverage
Property Coverage
Commercial Auto /Truck
Workers Compensation
Not Sure Request a Call
25
Annual Gross Receipts:
26
Total Number of Employees:
27
Annual Payroll:
28
Are subcontractors being used? What are their duties and how much do you spend on subcontractors annually?
29
Please describe the business:
30
Any foreign operations?
31
Is the business currently insured?
32
Any claims in the last 5 years?
33
Is a Wavier of Subornation or Additional Insured's needed to be listed?
34
Property Coverage Request?
Yes, I need building to be covered
No, Not needed
35
Do you lease space to others?
36
Is the entity the building owner or tenant?
37
What year was the building built?
38
Construction type of building and roof?
39
Size and Square Feet of building and when was it built?
Sq Feet And Year Built
40
Does it have a monitored burglar or fire alarm?
41
Does the building have a sprinkler system?
42
How much would it cost to replace all the property inside the building?
43
Is any space leased out?
44
Are tenants you lease to required to list you as additional insured on their insurance?
45
Please describe any property claims in the last 5 years.
46
Commercial Auto Coverage?
Yes, I use a vehicle for business
No, All vehicle are personal
47
How many vehicles do you have?
48
Do employees take any vehicles home?
49
Garage Locations
50
Copy of Driver's list (include names, date of birth and driver license numbers), Copy of Vehicles List: Year, Make, Model and VIN#.
Drag and drop files here
Select files to upload
Max. file size: 1.0MB
Cancelof
51
Description of what vehicles are used for:
52
Describe any auto claims in the last 5 years:
53
Umbrella Coverage
54
Do you have a commercial umbrella?
55
How much coverage do you think you need?
56
Workers Compensation Coverage?
Yes, and I have a crew
Yes, Just me Only
No, not needed
57
List Owners and Payroll for each:
58
List of Employees with Annual Payroll and Each Employees Occupation and Duties:
59
Do you use subcontractors? if Yes, What percentage of Annual gross income is spent on subcontractors?
60
Have you had any claims? If Yes, Please give Description:
61

aDDITIONAL INFORMATION TO INCLUDE:
62
OPTIONAL:
Should be Empty: