Insurance Quote Form

Name*

First NameLast Name
Insurance Quote

Please fill in the form below and I will reply to your email based on the information provided.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail*
Email
Phone Number*
Your Business Name*
Company Name
Business Description*
Business Description
Type of entity

IndividualPartnershipCorporationLLCDBAOTHER
Is work address the same as home address?

YesNo
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Details
Please provide us with information on your services, pricing, and the detail of your requested services.
Annual Income

15000 - 2000025000 - 5000055000 - 100000100000 - 500000
Liability Limits Per Occurrence/Aggregate

1000000/$20000002000000/$4000000
Type of Commercial Coverage

General LiabilityPersonal Property/Business Owner's PolicyCommercial Auto
Personal Insurance

AutoHomePersonal UmbrellaLife
Year, Make, Model, of all vehicles. All licensed Drivers Name(s), Date of Birth
Home Insurance - indicate rents to others, vacant, or primary home. Include owner's names and dates of birth.
List all motor sport vehicles (boats, motorcycles, etc) List any other owned property and use.
Life Insurance - indicate Term insurance or Whole life insurance. Include name, date of birth, height, weight, medications, and any health diagnosis such as diabetes, etc. and surgeries.
What best describes your line of work?

BeauticianBarberHair StylistEstheticiansOther
Have any insurance claims been filed against you in the past 10 years?

YesNo
The following activities will be excluded from your policy. Please confirm that you acknowledge that you will not be covered for any of the following:

Any products, supplies, accessories, or tools that you sell, distribute, supply, develop, or manufacture, including private labelling of products manufactured by others, Body contouring or fat reduction, including but not limited to ultrasonic cavitation

Chemical peels
Ear candling
Hair implants or transplants
Lash extension
Medical or healthcare services, including but not limited to prescribing and administering prescription medications
Medical-grade facials or hydrafacials
Microdermabrasion or microneedling
Permanent makeup
Services on or for minors
Wigs or toupees
Please confirm that you acknowledge that you will not be covered for any of the exclusions listed above:
Should be Empty:

Insurance Quote

Service Details