Request for Business Insurance Quote

Request for Business Insurance Quote

In-house use only do not send to client.
Completed By:
Agency Name *
enter agency prefix
Producer Names (LSI) *
Producer Names (Rouland) *
Producer Names (HRC) *
Producer Names (JCI) *
Producer Names (Elite One) *
For Edit Submission
Date *

Month Day Year
Date
How did you hear about us? *
Referred by: *
If known otherwise type Unknown
Notes:
Applicant Information:
Legal Entity Type
First & Last Name of Applicant
What is the Legal Name of the business
Does the Applicant use a DBA different from the Legal Name
(Doing Business As)
What is the name of the DBA
When did the Business originally start
When did the bus. first open (Month/Year)
When was this Entity established
Example - when they became Corp or LLC
What is the Social Media Page
How do we find in Facebook / other social media platform? Enter NONE if they don't have any.
What is the website for the business
Enter NONE if no website
Does Business have Insurance now
Do they currently have a policy
Name of Carrier
Number of Years with this Carrier
When does the policy expire
enter the exp / renewal date
Business Contacts:
First & Last Name *
Primary Contact Person
Phone Number *
Email Address *
Is there a 2nd Contact *
First & Last Name *
Secondary Contact Person
Phone Number *
Email Address *
Applicant Address:

Physical Address (map it) *

	Address
Street
City
State
Zip

Address Type *

Mailing Address (map it) *

	Address
Street
City
State
Zip

General Policy Information:
Class of Business
Sub Class of Business
Gross Sales
Liquor Sales
Square Footage
Does the Business have any employees (Excluding Business Owner)
Number of Full Time Employees (32 Hours or more per week)
Number of Part Time Employees ( under 32 Hours per week)
What is Estimated payroll for the next 12 months (Business Owner only)
What is Estimated payroll for the next 12 months (Employees only)
What is Estimated payroll for the next 12 months (Contractors only)
Does the Business have a physical location?
How many locations?
Does the Applicant own this building?
Does the Applicant want to have insurance for this building (Replacement Coverage)
Describe this location (Building type)
Describe the construction type for this location
What is the year built of this location?
What is the number of Stories?
What is the total square footage of this building?
What is the square footage occupied by Applicant?
Number of Residential Units
Does the Building have automatic Sprinkler System (cannot be Partial)
Does this building have Central Reporting Fire Alarm
Does this Building have Central Reporting Burglar Alarm
Does this building have security Cameras?
Does this building have Automatic Commercial cooking Fire Extinguisher system (aka fire suppression system)
Collect Quote info another LOB *

Auto Renters (HO4) Condo (HO6) Landlord (DP3) Boat Earthquake (not ready for use) Flood (not ready for use) RV (not ready for use) Motorcycle (not ready for use) None / No Other LOB at this time.
* This will transfer the client info to another quote form to save time. Example - if a client calls for a home quote but also wants an auto quote. The you can transfer the data to the auto quote form and eliminate typing the same information multiple times.
Should be Empty: