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Business Quote Request
Please complete the following questions for your business insurance quotes.
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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
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2
Primary Contact Information
*
This field is required.
First Name
Last Name
Email Address
Phone Number
Mailing Address
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3
Business Information
*
This field is required.
Name of Business
Year Started
Please Select
Sole Proprietor
LLC
Corporation
Partnership
Non-Profit
Joint Venture
Other
Please Select
Please Select
Sole Proprietor
LLC
Corporation
Partnership
Non-Profit
Joint Venture
Other
Type of Entity
Estimated Annual Revenue
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4
Additional Business Information
Number of Active LLC Owners
FEIN
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5
Any prior insurance for this business?
*
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YES
NO
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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?
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7
Does the business have employees?
*
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YES
NO
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8
Employee Questions
How many Full Time Employees?
How Many Part-Time Employees?
Estimated Annual Payroll
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9
Detailed Business Description
*
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Please describe what the business does and any incidental operations.
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10
Is this Builders Risk for new construction?
YES
NO
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11
Builders Risk Information
Property Address
Total Square Footage
Cost of Construction
Estimated Occupancy Date
Name of General Contractor
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12
Builders Risk Information - Renovation
Property Address
Total Square Footage
Cost of Construction
Original Year Built
Estimated Occupancy Date
Name of General Contractor
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13
Umbrella Limits Requested:
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000+
Please Select
Please Select
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000+
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14
Please indicate any other states or countries you operate in:
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15
Is an umbrella required by a contract or agreement?
YES
NO
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16
Please attach a draft or sample of contract if available:
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Select files to upload
Max. file size
: 10.6MB
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17
How many active Directors & Officers are there in entity?
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18
List all the professional services you provide:
If applicable, list what % these services make up the business.
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19
Type of Property Coverage Requested
Building Coverage
Contents Coverage
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20
How much contents coverage is needed?
Please list a $ amount.
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21
Property Location(s)
List all addresses you wish to seek coverage on
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22
Is this property a new purchase?
YES
NO
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23
New Purchase Questions
Estimated Closing Date
Name of Lender (If Applicable)
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24
Type of Occupancy
1-4 Unit Dwelling
5+ Unit Apartment Building
Retail
Office
Manufacturing
Restaurant
Other
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25
Describe Occupancy
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26
Was the property constructed before 2003?
YES
NO
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27
Which of the following been updated in the past 20 years?
Roof
Plumbing
Heating
Electrical
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28
Vehicle Information
Year, Make, Model and VIN of Vehicle
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29
Driver Information
*
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Name, Date of Birth, and Drivers License Number
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30
Does the business hire subcontractors?
YES
NO
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31
Subcontractor Questions
Annual Cost of Subcontractors
Type of Work Performed by Subs
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32
Additional Comments
Coverage limits requested, special requests, anything you'd like us to know.
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