Underwood Insurance - Commercial Package Quote Request Form

Commercial Package Quote Request Form

Underwood Insurance
Contact Name

First NameLast Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Information
Business Name
Doing Business As: (If applicable)
Nature of Business
Date Business Started

MonthDayYear
Date
Address

Business Address

Street Address Line 2

Business CityBusiness State

Business Zip
Business Phone
Format: (000) 000-0000.
Business Fax
Business Email
example@example.com
Tax ID
Gross Annual Sales
Number of Full Time Employees
Number of Part Time Employees
Monthly Payroll
Number of Locations

Building Information
Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year Built
Square Footage
Sprinkler
Construction Type
Are you the Owner or Tenant?
If you are the Owner, Do you lease any part of the Building to Others?
Percentage of Builidng Leased to Others
Who Occupies the Leased Area?
Amount of Business Personal Property at this Location
Amount of Sales/Rents at this Location
Is Coverage Needed for Equipment?

Liability Information
Please Describe your Business Operations
Do you furnish Certificates to Other Businesses?
What is your current Employee payroll?
Do you use Subcontractors?
What Percentage of Work is Subcontracted?
What is your current amount paid to Subcontractors?
What Percentage of your work is residential?
What Percentage of your work is commercial?
What is your Current Liability Limit?
Is an Umbrella Policy Needed?
Is the Business a New Venture?

Loss Information
Number of Losses in the past 5 Years
Additional Information
Is Workers Compensation Needed?
Is Busness Auto Coverage Needed?
Referred By
Preferred Contact
Notes
Should be Empty: