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Business Insurance Quote Form
Fill the fields below accurately and we will contact you shortly.
Contact Person
*
First Name
Last Name
E-Mail
*
Email
Phone Number
*
Format: (000) 000-0000.
Legal Company Name / DBA Name
*
Company Name
Business Description and Type
Business Description
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Start date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service Details
Insurance Products You Are Interested In
*
General Property
Workers Compensation
Liquor Liability
General Liability
Business Property
Other
Value Of Coverage
Rows
Coverage Amount in 000
General Property
Liquor Liability
Business Property
Workers Compensation
General Liability
Other
Best Time to Call
Minutes
AM
PM
AM/PM Option
Annual Lotto Sales
FEIN/TAX ID
*
optional
Annual Gross Sales
*
optional
Annual Gasoline Gallons
optional
Years in Business
*
optional
Additional Insurer Needs ( Landlord or Mortgage Bank ):
Property Coverage
*
Please Select
Yes
No
Choose Type of Coverage ?
*
Building
Contents
Gas Canopy
Gas Pumps
Sign
Business Income with Extra Income
Business Income without Extra Income
Equipment Break Down
Spoilage
Theft
Terrorist Act
Wind
Hailstorm
Sink Hole
Coverage Details
Rows
Value in 000 USD required
Building
Contents
Gas Canopy
Gas Pumps
Sign
Business with Extra Income
Equipment Break Down
Spoliage / Damage
Theft
Terrorist Act
Do You need Wind / Hail Coverage
*
Please Select
Yes
No
Building Value ?
*
How much would it cost to replace all the property inside the building?(Contents)
*
Does the building have a sprinkler system?
*
Please Select
Yes
No
How many Gas Pumps?
Please Select
1
2
3
4
5
6
7
8
9
10
10+
Is the entity the building owner or tenant?
*
Please Select
Owner
Tenant
Other
Do you lease space to others?
*
Please Select
Yes
No
Is there any cooking on premise?
*
Please Select
Yes
No
What type of Business ?
Is there a propane Exchange?
*
Please Select
Yes
No
is there propane filling station on premise ?
*
Please Select
Yes
No
Is there car Wash ?
*
Please Select
Yes
No
Roof Update year ?
*
HVAC Update year ?
*
Plumbing Update year ?
*
Electric Update Year ?
*
Any Claims in the last 5 years
*
Please Select
Yes
No
If Answer is yes , Please describe any Property or Liability Claims in the last 5 years.
Any Other Information or Ask ?
Upload Files - Please upload your existing policy documents inacse you are plannign to renew or switch.This will ensure we dont have any Gaps in the policy.
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