Business Insurance Quote Form
Person & Contact Details
How did you hear about us?
Please Select
A customer referred me
Google
Website
Saw Our Sign
George Restaurant
Mortgage Lender Referred Me
My Relator Referred Me
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do We have permission to communicate via text with you at this number? By selecting Yes, you agree to receive text messages from Spitzer Insurance Agency . Message frequency may vary. Message and data rates may apply. Text HELP for assistance. To opt-out at any time, reply STOP.
*
Yes
No
Name of Business
Describe your business and what all it does. Please be detailed so that we can explain to underwriters as well as get you accurate supplemental applications to expedite the quote turn around.
When was the business established?
-
Month
-
Day
Year
Entity Type
Please Select
Sole Proprietor
LLC
Corporation
Non-Profit
Other
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your estimated annual gross revenue?
Do you have any employees?
Please Select
Yes
No
What is your estimated annual payroll NOT including yourself?
Does your business have any property that needs to be insured? Such as building, equipment, supplies, tools, etc?
Do you have any business autos?
Please Select
Yes
No
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Commercial Vehicle Details
(if not applicable please click next)
What is the Name, date of birth and drivers license numbers of all drivers that need to be listed on the policy?
What is the year, make & model of EACH vehicle you would like insured?
*
Example: 21 Ford F150/ 17 Toyota Prius
What are the vin numbers of all the vehicle(s)?
Do you want Comprehsnive Coverage on your vehicles?
Yes
No
Do you want Collision Coverage on your vehicles?
Yes
No
What is the farthest radius your business operates?
Example: 100 miles
Do you need to insure extras? Please add what extras you would like to insure, with the value.
*
Example: Custom Wheels
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Next
Please upload current declaration page if available.
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