Questionnaire for Insurance Quote with BF

Quote Request for Business or Professional Liability Insurance
Company Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Start Date

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How did you hear about us?*
What type of business is this?*
What type of Insurance do you need?*

Business Owners PolicyCommercial General LiabilityProfessional LiabilityErrors & OmissionsMalpractice InsuranceNo Exam Term LifeEvent LiabilityBonds
Are you currently insured? If yes retroactive date? Date What is your annual Premium?
Please describe your Industry be specific*
What is your expected annual revenue?*
How many employees do you have?
What is your annual payroll?*
Have you had any claims against your previous policy? If yes, please describe.

Authorization to gather & share information needed to shop, purchase, cancel new Insurance policy per client consent and Standard Broker Fee Agreement
1. The parties to this agreement are (The Client) and EandO Global Insurance & Financial Services, California Department of Insurance License Number 6002837 ("BROKER").
2. (The Client) appoints BROKER as (The Client)'s insurance broker of record.
3. This agreement shall become operative on the (Effective date) and shall continue in full force until terminated by either party.
4. BROKER agrees to represent (The Client) honestly and competently.
5. (The Client) agrees to pay BROKER a broker fee for BROKER'S services. The broker fee varies. The broker fee IS / IS NOT refundable.
6. BROKER may in the future charge (The Client), and (The Client) agrees to pay, additional fee(s) for the services listed below. There may be additional fees for additional services.
7. Following are the nature and amount of all fees known to BROKER that will be charged by persons other than BROKER or the insurance company in connection with current placement of (The Client)'s insurance. These fees are not retained by BROKER.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Quote Request for Business or Professional Liability Insurance