Business Insurance Quote Form

Business Insurance Quote

(440) 943-7000 - Howell@uainc.com
How did you hear about us?
If other, please describe:
If referral, let us know who:
General Information
Contact:

First NameLast Name
E-Mail:
Email
Phone Number:
Mailing Address:

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Company Name:
Company Name
Company Website:
Legal Entity:

NonprofitCorporationPartnershipIndividualLLCOther
Year Business Established:
FEIN:
Description of Business Operations:
Insurance Coverage Requested:

General LiabilityProperty CoverageCommercial AutoOther
Current Insurance Carrier:
Current Policy Expiration:

MonthDayYear
Date
General Liability Coverage
Gross Annual Revenue ($):
Gross Annual Payroll ($):
Gross Annual Subcontractor Payroll ($):

Number of Employees:

	Owners	Full-Time	Part-Time
Total Number

Building Locations:

Building Property/Equipment:

	Owned Business Personal Property Value ($)	Rented/Leased Equipment Value ($)
Building #1
Building #2
Building #3
Building #4

Building Updates (Year):

Building Security:

Vehicle Information:

Vehicle Coverage:

Driver Information:

*Personal Information about you, including information regarding a credit report, may be collected from persons other than you, in connection with this insurance application and subsequent renewals*

After you hit the SUBMIT button, we'll send you a copy of this worksheet for your records and reach out to you once we review your information.

Please click the SUBMIT button now. Thank you!
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Business Insurance Quote