Commercial Insurance Quote form
Please contact Courtney for any questions Email-levatoinsured@gmail.com #609-820-7267
Applicant Name
First Name
Last Name
Email
example@example.com
Primary Contact #
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Name
Name of Owner(s) full name(s)
First Name
Last Name
Percentage of ownership
Name of Owner(s) full name(s)
First Name
Last Name
Percentage of ownership
How many years of experience in industry?
Any affiliated or subsidiary businesses?
yes
no
Any additional coverages needed (e.g., products/completed ops, personal & advertising injury)?
Any Additional Insureds
Legal Entity
Nonprofit
Corporation
Partnership
Individual
LLC
Other
Business established date
-
Month
-
Day
Year
Date
FEIN
SIC Code
Number of employees
Nature of business operations (detailed description)
Gross Annual Payroll ($)
Gross Annual Revenue ($)
Insurance coverage requested
General Liability
Commercial Property
Business Owner Policy (BOP)
Professional Liabilty (E&O)
Workers' compensation
Umbrella/Excess Liability
Cyber Liability
Other
File Upload
Browse Files
Drag and drop files here
Choose a file
Please upload current policy document's If you are currently Insured
Cancel
of
Current Insurance Carrier
Current Policy Expiration Date
-
Month
-
Day
Year
Date
Current Policy Retroactive Date
-
Month
-
Day
Year
Date
Desired Effective Date for New Policy
-
Month
-
Day
Year
Date
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PROPERTY DETAILS
Are you requesting Property Coverage
Yes
No
Building ownership
owned
leased
Tenants or shared occupancy
other
Current Carrier
Building Information
Construction Type
Please Select
fire-resistive
non-combustible
ordinary
heavy timber
wood-framed
other
Year Built
Insured sq feet
Unoccupied sq feet
Year Renovated
Rows
Renovated Year
Roof
Electrical
Plumbing
Heating
Building Security
Rows
Local
Central
None
Fire Alarm
Burglar Alarm
Building Property Value ($)
Building Property Value ($)
Building Property Value ($)
Personal Property Value ($)
Annual Gross Revenue ($)
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GENERAL LIABILITY
Are you requesting General Liability Coverage
Yes
No
Desired Amount of General Liability Coverage ($)1M/$2M
Rows
Yes
No
Are any autos used exclusively for business use?
Do any employees use a personal auto for business use?
Are any web based services offered?
Is there Underground Tank Leakage Exposure?
Is there a Pollution Exposure?
Any work performed off-site or at customer locations?
Any hazardous materials or equipment used?
Any work at heights, underground, or involving demolition?
Are customers or the public allowed on-site?
Any general liability claims in the past 5 years? (If yes, provide details: date, type of claim, amount paid)
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Professional Liability
Are you requesting Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered?
Does your firm provide services outside the U.S.?
Yes
No
Percentage of Services for the outside the U.S
Is there a formal Safety Plan?
Yes
No
Does your firm use Independent Contractors (ICs) or Sub Contractors?
Yes
No
What is the percentage of your firm’s gross Fees paid to ICs or Sub Contractors last year?
Rows
Yes
No
Do you request Certificates of Insurance from ICs and Sub Contractors?
Do you have written agreements on every project?
Do ICs and Sub Contractors have written agreements?
Do you provide Professional Liability to your ICs and Sub Contractors?
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Medical Professional Liability
Are you requesting Medical Professional Liability Coverage?
Yes
No
Desired Amount of Professional Liability Coverage ($)
Describe Professional Services offered
Does your firm use Independent Contractors (ICs) or Subcontractors?
Yes
No
Rows
Yes
No
Do you employ Physicians or Surgeons?
Is there a Medical Director?
Does the Medical Director have their own insurance?
Do you request Certificates of Insurance from ICs and Subcontractors?
Do you have written agreements on every project?
Do ICs and SubContractors have written agreements?
Do you provide Professional Liability to your ICs and Subcontractors?
Do you bill for Medicare/Medicaid?
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Worker's Compensation
Are you requesting Workers’ Compensation Coverage?
Yes
No
Number of Employees
Rows
Full-time
Part-time
Number of Employees
Number of Independent Contractors (ICs)
Rows
Full-time
Part-time
Number of Independent Contractors (ICs)
Estimated annual payroll by job classification
Job duties for each class of employee
Any employees working out of state? (If yes, where?)
Any 1099 independent contractors? If yes, % of total labor
Are Medical Benefits Offered?
Yes
No
Do you offer Paid Vacation?
Yes
No
Is there a formal Safety Program?
Yes
No
Total Estimated Payroll ($)
Do you have a website or social media for your business
Submit
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