Commercial Insurance Quote Request
Fill in Applicable Information for Your Quote Request
General Business Information (Required)
What would you like a quote for? (General Liability, Commercial Auto, Property, Work Comp, Inland Marine)
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Is this a New Venture? When did you Start the Business?
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What is the nature of your business
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Legal Name of the Business
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Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Owner/Officer Name
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First Name
Last Name
Owner/Officer Name
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First Name
Last Name
Primary Owner DOB:
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Physical Address of Business
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address if different
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who do you have your insurance with now and how long have you been with them?
Can you tell me a little about why you're shopping today?
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Commercial Auto Insurance Questions
Do you know what your current bodily injury limits are? 25/50, 50/100, 100/300, 250/500
Do you currently have UM/UIM? Do you know the coverage?
List of Drivers for the business: Name, Birthdate, Driver's License numbers
Vehicle 1 - VIN#, year, Make, model
Vehicle 1
Vehicle 2 VIN#, year, Make, model
Vehicle 2
Vehicle 3 - VIN#, year, Make, model
Vehicle 3
Vehicle 4 - VIN#, year, Make, model
Vehicle 4
More than 4 vehicles list here: VIN#, year, make, model, years owned
What coverages do you have on Vehicle 1? Collision, Comp, Rental, Roadside, Gap, Deductible?
What coverages do you have on Vehicle 2? Collision, Comp, Rental, Roadside, Gap, Deductible?
What coverages do you have on Vehicle 3? Collision, Comp, Rental, Roadside, Gap, Deductible?
What coverages do you have on Vehicle 4? Collision, Comp, Rental, Roadside, Gap, Deductible?
What coverages do you have for the rest of your vehicles? Collision, Comp, Rental, Roadside, Gap
Have you had any accidents or claims in the last 5 years? If so, what happened?
Property Insurance Questions
What is the square footage of the house/building that needs insured for your business?
Year Built
Exterior material: vinyl, brick, stone, cement board, etc.
Number of stories:
Type of Roof and Age of Roof
Foundation Material
Any other detached structures?
Have you had any claims in the last 5 years? If so, what happened?
Workers Comp Coverage
Federal Tax ID for Business (Required if requesting a quote)
How many employees do you have?
What are their job duties and what is their annual salaries for each job duty? (You can total employees salaries together that have the same job duties.)
Additional Follow-up Coverage Questions
Additional Notes - Provide any additional information you feel would be helpful
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