Commercial Insurance Quote Form

Commercial Insurance Quote Form
Company Legal Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Coverage Start Date

MonthDayYear
Date
Legal Owner of Company 1

First NameLast Name
Date of Birth

MonthDayYear
Date
Legal Owner of Company 2

First NameLast Name
Date of Birth

MonthDayYear
Date
If there are more owners of the company, please indicate in the general information section at the end of this form.
What type of commercial insurance are you looking for?

Retail OperationConstruction Industry Risks (ie contractor, electrician, plumber, painter)Residential RealtyRetail OperationProfessional Services (ie doctors office, accountants office etc.)Other
Please provide me me a brief description of your business activities:
How long have you been in business?
How long have you had business insurance for?
Have you had any claims in the past 5 years?
What are your gross annual receipts?
Gross annual receipts are the total amount of income generated before subtracting costs or expenses. This is required to help determine the liability rate and to provide loss of income coverage.
Do you own the building where your business is situated? Does it require coverage?
Please provide me with some construction details on your building.
Year built, heat source and updates, electrical type and update
Value of tools to be covered:
Typically items valued at less than $1,500 are considered tools.
Value of equipment to be covered:
Typically items valued at greater than $1,500 are considered equipment.
Value of stock to be covered:
This is the products and inventory of the business.
How many employees do you have?
Do you agree to including insurance score (soft credit check) with your quote?
Completing a soft credit check may provide further savings on your policy. There is no information collected or viewed and it does not impact your credit score.
Please indicate home address for each applicant.
General information regarding your business.
If you have any questions, please feel free to contact me directly with any questions. I can be reached at 519 461 9408 or mgarner@heartlandfarmmutual.com
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