Edmonds Agency / Business Insurance Quote
Please accurately fill the fields below.
Personal Information
Name
First Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Owner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Owner's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
BUSINESS INFORMATION
Business Name
Business Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Web Address
Business Entity:
Individual
Partnership
Corporation
LLC
Joint Venue
Association
Other
Please provide the FEIN (Federal Tax ID) for the Business
Do you have Personal Lines Policies with Farmers?
Yes
No
What year was the business established/acquired by the current owner?
Has the owner maintained continuous insurance coverage for the business?
Yes
No
How many years of management experience in this industry does the applicant have?
Description of Business Operations:
Is this a home based business?
Yes
No
Number of Full-time Employees
Number of Part-time Employees
Total Annual Receipts
What are the regular daily hours of operation at this location?
How many locations does your business have?
Seperate Form for multiple locations
Back
Next
PRIOR CARRIER INFORMATION
Carrier Name
Policy Expiration Date
Have you had any Business Insurance Policy cancelled in the last 3 years?
Yes
No
If "YES" to the above, please explain why.
AUTO DETAILS
Will there be commercial Auto/Autos included on this policy?
Yes
No
Description of Business Auto Operations:
NOTES:
Is there any other information you'd like to provide?
Submit
Should be Empty: