Business Insurance Quote request form
Ballentine Insurance Agency
Name of Business
*
Entity type
*
Individual/sole proprietorship
Partnership
Corporation
LLC
Corporation
Joint Venture
Association
Other
Owner name(s)
*
FEIN
Address
*
Year Business established
*
Nature of Business
*
IE- restaurant, retail, auto repair, landscaping, etc.
email
*
phone
*
Year business started
*
Annual Revenue
*
If new venture- estimated annual revenue
Number of employees
*
Full time employees / Part time employees
Overview of business operation
*
Current carrier
Current insurance company. If new business, leave blank
Best time for call
Line of business to quote: Select all that apply
*
Workers Compensation
General Liability
Property Coverage
Commercial Auto
Professional Liability (Errors & Omissions or Directors & Officers)
Key Man Life policy
Umbrella
additional notes or request
Submit
Should be Empty: