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Commercial Lines Quote Form
How did you hear about us?
*
Please Select
Google
Facebook
Other Social Media
Referral
Newspaper Ad
Saw Your Sign
My Mortgage Lender Referred Me
My Realtor Referred Me
Current Customer
Josh Reed
Nicole Thomas
Mandy Reed
Jennifer Trenhaile
Katia Tatum
Christine Nunez
Kimla Casey
Kaylee Sturgeon
Name
*
First Name
Last Name
Name Of Business
*
What is your EIN?
What Kind of Insurance are you Shopping for?
General Liability o
Property
Work Comp
Health
Auto
Other
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 Business Established
*
/
Month
/
Day
Year
Date
Entity Type
*
Sole Proprietor, LLC, Corporation, Non-Profit, Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have permission to communicate via text with you at this number?
*
Yes
No
Business Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Mailing Address the same as the physical address?
Yes
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Desired Coverage Start Date
*
/
Month
/
Day
Year
Date
What Is Your Estimated Annual Gross Revenue?
*
Do you have employees?
*
Please Select
Yes
No
How Many Employees (Do not count yourself)
What is your estimated annual payroll NOT including yourself?
Commercial Information
Have You Ever Had Insurance On This Business Before?
*
Please Select
Yes
No
Does Your Business Have Any Property That Needs To Be Insured? Such as equipment, supplies etc.
*
Auto
Company Name and DOT Number
Company Name
DOT Number
Do you have a CDL
Yes
No
Enter Your Drivers License State and Complete Number
How many Vehicles do you drive for this business?
How many Drivers do you have?
What is the furthest One way distance you will drive 90% of the time?
What is the Gross Weight of the Vehicle? (Empty)
What is the value of any attached equipment. Such as shelves and other attached modifications?
What is the value of each vehicle? (Please list if multiple.)
Do you require any filings? Please check all that apply.
Federal Liability Filing
MCS-90
State
Other
Do you have a Business General Liability Policy or Business Owners Policy in Place?
How would you like us to contact you for additional questions and to follow up?
Phone Call
Text me
Email Me
Group Health Information
Do you have common ownership in any other business?
Please Select
Yes
No
How many W2 employees other than the owner(s) and spouse do you have?
What is your current probationary period for new hires to be eligible for health coverage?
How many hours do you require an employee to work to be eligible for health insurance?
Will only certain classes of employees be eligible for health coverage (such as management, salary employees, etc.)?
Are you interested in offering ancillary benefits such as dental & vision?
Please Select
Yes
No
Please upload current declarations page if available
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