Biz General Info

Business Insurance Quote Form

General Information
Please complete the below in its entirety. For fastest turnaround, please make sure ALL fields are answered.

Please be sure to let us know how soon you need coverage.

Thank you!!
Name *

First Name Last Name
Entity Type *

Sole Proprietor Partnership Limited Liability Corporation (LLC) S-Corporation C-Corporation
Full Business Name, including DBA (if applicable) *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Physical Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
Website: *
Preferred Method of Contact *

Phone Text Email Zoom
How Did You Hear About Us? *
Date business started: *

Month Day Year
Date
What is your FEIN? *
xxxxxxxxx (do not add dashes)
Provide a brief description of your operations: *
We sell... we make... we build... we are awesome!
Do you own 50% or more in any other business? *

Yes No
If yes, please explain the nature of that business, and your involvement in that business
Do you require any state or federal filings, and/or do you have a contractor's license? *

Yes No
If yes, please provide those numbers here
Do you have any other agents working on your account at present? *

Yes No
If yes, please describe:
If so, we may be blocked from certain markets; if you would like us to proceed we will need you to sign an agent of record change letter
What type(s) of coverage are you looking for? *
General Liability, Work Comp, Commercial Auto, Property, Professional Liability, something to make my landlord happy, etc.
How soon do you need coverage to begin? *

Month Day Year
Date
What is your estimated annual sales/revenue? *
General Liability, Work Comp, Commercial Auto, Property, Professional Liability, something to make my landlord happy, etc.
What is your estimated annual payroll? *
General Liability, Work Comp, Commercial Auto, Property, Professional Liability, something to make my landlord happy, etc.
Provide details about your location: *
Year built (if over 25 years old, provide most recent year updates were done for electrical, roof, hvac, plumbing), square feet occupied, construction type, roof material, does your space have 100% fire suppression sprinklers, does your space have a central burglar/fire alarm (if so, who is the responding company).
Have you had any claims or losses within the last 3 years? *
If yes, provide date of loss and payout amount for each claim/loss, or upload your claims history
Are you interested in getting more information about... *

Group health? Payroll services? Merchant services? CPA / Bookkeeping services?
Please upload a current copy of your policy

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Business Insurance Quote Form