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Request for a commercial insurance quote
Please fill the form accurately for better assistance
Person & Contact Details
Applicant's Name
*
First Name
Last Name
Email
*
example@example.com
Enter a valid Phone Number
*
Format: (000) 000-0000.
Insured's Operation:
*
Description of Building
*
Physical Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where did you hear about us
*
Google Ads
Yelp
Facebook
Website
LinkedIn
Other
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New Busines - Type of Business:
*
Individual
Partnership
Association
Joint Venture
Corporation
Other
If "Other" was selected above, please explain type of business
PROPERTY COVERAGE INFORMATION
*
Rows
Yes
No
Coverage Amount
Building
Contents
Improvement & Better
OPTIONAL COVERAGE
Rows
Yes
No
Coverage Amount
Replacement Cost
Off Premises
Agreed Value (Include Statement of Values)
Inflation Guard
Other
Mortgage Policy Number
Loan Amount
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OPTIONAL COVERAGE
Off Premises
Agreed Value (must include form CP1515)
Other
If other was selected above, please explain:
GLASS
Blanket
Schedule
If Schedule was select above, please explain:
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LIABILITY COVERAGE INFORMATION
Rows
Coverage Amount
General Aggregate
Products/Completed Operations
Per Occurrence Limit
Personal & Advertising Injury Limit
Fire Damage Limit (any one fire)
Medical Expenses Limit (any one person)
Annual Payroll
Annual Sales
Hired & Non-owned (100/300/50)
Employer's Liability (Stop Cap)
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CRIME COVERAGE INFORMATION
Coverage A: Employee Dishonesty Class I
Coverage A: Employee Dishonesty Class II
Coverage B: Forgery or Alternation Inside
Coverage B: Forgery of Alternation Outside
Coverage C: Theft
Coverage C: Dis
Coverage C: Destruction
Safe
Alarm
Guards
Armored Service
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INLAND MARINE COVERAGE INFORMATION
Rows
Limited of Insurance
Deductible
EDP Hardware
EDP Software
Signs
Valuable Papers
Account Receivables
Physicians & Surgeons Equipment
All Risk Transportation
Miscellaneous Prop. Floater
Installation Floater
Contractor Equipment Leased
Contractor Equipment Schedule
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Number of Vehicles
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BOILER AND MACHINERY COVERGE INFORMATION
Rows
Limit $
Description of Boiler
COMMERCIAL AUTOMOBILE COVERAGE INFORMATION
Rows
Deductible
Limit
DRIVER INFORMATION
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COMMERCIAL UMBRELLA COVERAGE
$1,000,000
Limit SIR $10,000
Alternative Limit
If Alternative Limit was selected above, please indicate amount
Comments
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I understand
*
This Application does no obligate the Applicant to purchase insurance nor bind the Organization to effect insurance. The undersigned further agrees, that the insurer may alter or revoke any quotation previously rendered upon receipt of changes to the information provided in the Application or accompanying documents.
I understand
*
Any person who knowingly and with the intent to defraud presents false information in an insurance request form, or who presents, helps, or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstance prevails, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. Any person who, knowingly and with intent to defraud the insurance company or other person, files an application for insurance containing any false information or conceals for misleading, information containing any fact material thereto, commits a fraudulent insurance act violation, which is a crime.
Please verify that you are human
*
Signature
*
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