Commercial Lines Quote Form

Commercial Lines Quote Form
How did you hear about us?
What type of insurance quote are you requesting?
Name

First NameLast Name
Name Of Business
What is your EIN?
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

MonthDayYear
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.
Business Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Mailing Address the same as the physical address?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Desired Coverage Start Date

MonthDayYear
Date
What Is Your Estimated Annual Gross Revenue?
Do you have employees?
What is your estimated annual payroll NOT including yourself?
Commercial Information
Do You Have Any Business Autos?
Does Your Business Serve Alcohol?
Have You Ever Had Insurance On This Business Before?
Does Your Business Have Any Property That Needs To Be Insured? Such as equipment, supplies etc.
Amazon/Commercial Auto Information
Company Name and DOT Number

Company NameDOT Number
Do you have a CDL
Enter Drivers License State and Complete Number
Please list all drivers on policy
How many Vehicles do you drive for this business?
What is the VIN and Vehicle Type for EACH vehicle. (Please list)
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.

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?
Group Health Information
Do you have common ownership in any other business?
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 list names, dates of birth, zip code of where they live and classification (employee, owner, dependent) of all seeking to be insured
You can bypass this question by uploading a census if you have it below
Please upload current declarations page if available

Cancelof
Any additional notes you would like us to know?
Should be Empty:

Commercial Lines Quote Form

Commercial Information

Amazon/Commercial Auto Information

Group Health Information