Business Quote Request

1
Type of Insurance Requested* This field is required.
General Liability
Property
Workers Compensation
Commercial Auto
Professional Liability
Commercial Umbrella
Directors & Officers
Inland Marine
Builders Risk
2
Primary Contact Information* This field is required.
First Name
Last Name
Email Address
Phone Number
Mailing Address
3
Business Information* This field is required.
Name of Business
Year Started
Please Select
Please Select
Sole Proprietor
LLC
Corporation
Partnership
Non-Profit
Joint Venture
Other
Type of Entity
Estimated Annual Revenue
4
Additional Business Information
Number of Active LLC Owners
FEIN
5
Any prior insurance for this business?* This field is required.
YESNO
6
Prior Insurance
Name of Prior Insurance Company
Type of Prior Insurance ex. General Liability, Commercial Auto, etc.
Reason for Shopping
Any Insurance Claims in the past 5 years?
7
Does the business have employees?* This field is required.
YESNO
8
Employee Questions
How many Full Time Employees?
How Many Part-Time Employees?
Estimated Annual Payroll
9
Detailed Business Description* This field is required.Please describe what the business does and any incidental operations.
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Small
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Ok
10
Is this Builders Risk for new construction?
YESNO
11
Builders Risk Information
Property Address
Total Square Footage
Cost of Construction
Estimated Occupancy Date
Name of General Contractor
12
Builders Risk Information - Renovation
Property Address
Total Square Footage
Cost of Construction
Original Year Built
Estimated Occupancy Date
Name of General Contractor
13
Umbrella Limits Requested:
Please Select
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000+
14
Please indicate any other states or countries you operate in:
15
Is an umbrella required by a contract or agreement?
YESNO
16
Please attach a draft or sample of contract if available:
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Select files to upload
Max. file size: 10.6MB
Cancelof
17
How many active Directors & Officers are there in entity?
18
List all the professional services you provide:If applicable, list what % these services make up the business.
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Ok
19
Type of Property Coverage Requested
Building Coverage
Contents Coverage
20
How much contents coverage is needed?Please list a $ amount.
21
Property Location(s)List all addresses you wish to seek coverage on
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Large
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Small
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Ok
22
Is this property a new purchase?
YESNO
23
New Purchase Questions
Estimated Closing Date
Name of Lender (If Applicable)
24
Type of Occupancy
1-4 Unit Dwelling
5+ Unit Apartment Building
Retail
Office
Manufacturing
Restaurant
Other
25
Describe Occupancy
26
Was the property constructed before 2003?
YESNO
27
Which of the following been updated in the past 20 years?
Roof
Plumbing
Heating
Electrical
28
Vehicle InformationYear, Make, Model and VIN of Vehicle
29
Driver Information* This field is required.Name, Date of Birth, and Drivers License Number
30
Does the business hire subcontractors?
YESNO
31
Subcontractor Questions
Annual Cost of Subcontractors
Type of Work Performed by Subs
32
Additional CommentsCoverage limits requested, special requests, anything you'd like us to know.
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Small
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Ok
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