Commercial Quote Form
Agent Name:
Please Select
New to Hoesli Insurance
Dustin Hoesli
Tonya Winchester
KC Martin
Miranda Strokosch
other
How did you hear about us?
Please Select
Internet search
Facebook
Billboard
Radio
We walked in & asked to quote your business
Newspaper
Dave Ramsey
Current customer referred you
Rep Came By
Notes
General Business Info:
Effective Date of Policy:
 -
Month
 -
Day
Year
Date
What would you like a quote for?
*
General Liability
Business Owners Policy
Inland Marine
Property
Commercial Auto
Work Comp
Other
Name of Business:
DBA: (if applies)
Select One:
LLC
Incorporated
Sole Proprietor
Other
Are you currently insured?
Yes
No
Name of current carrier:
Name of current broker or agency name:
Date Business Started:
 -
Month
 -
Day
Year
Date
FEIN for business:
** If no FEIN please use business owners SS#
Business Facebook link:
Carrier will do online underwriting so make sure to review this information with the client on the phone is possible.
Business website link:
Carrier will do online underwriting so make sure to review this information with the client on the phone is possible.
Number of total active owners:
List all additional owners below and percent ownership:
Primary Contact Name:
First Name
Last Name
Primary Contact Email:
example@example.com
Primary Contact Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Business Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the Insured own or lease the above business location?
Own
Lease
Is this the mailing address?
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
BOP / General Liability
Is this customer a contractor?
Yes
No
Is there sub-contracted work?
Yes
No
What is the total sub contracted payroll:
What is the total sub contracted materials cost:
Do you require COI's from all your subs?
Yes
No
Do you request to be listed as additional insured on your subs general liability and/or work comp?
Yes
No
Copy paste the current wording that is being requested:
Do you have any losses in the last three years?
Yes
No
Please provide a list of Losses below:
Last 12 Months Receipts/Sales
Total NON-Owner Payroll:
Total number of employees:
Property Insurance
Total Sq. Ft. of Building:
Construction Type:
Frame
Masonry Veneer
NON-Combustible
Other
Number of stories:
Foundation Type:
Slab
Crawlspace
Basement
Other
Year Built:
Year of improvements/upgrade:
*
Rows
Year Updated
Notes
HVAC
Electrical
Plumbing
Roof
Roof Type:
Hip
Flat
Gable
Other
Roof Materials:
Comp Shingle
Metal
Rolled Rubber Roof
Other
Does the building have a Sprinkler System?
Yes
No
What % of the building is sprinklered?
What percentage of building does the insured occupy?
Additional Tenant Information:
Total cost of tenant buildout and betterments:
Estimated building replacement cost:
Would you like building replacement cost coverage or actual cash value:
Replacement Cost Coverage
Actual Cash Value
Desired amount of Business Personal Property coverage?
Does the building have a Alarm System?
Yes
No
Please indicate the type of alarm present:
Central Station Fire
Central Reporting Burglar
Local Fire
Local Burglar
Other
Vehicle List
Vehicle List:
Rows
Year/Make/Model
VIN
Full or Liability
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle List Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Driver List
Driver List:
Rows
Name
DOB
DL Number
Driver 1
Driver 2
Driver 3
Driver 4
Driver List Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Equipment List
Type a question
Rows
Item Description
Value
Deductible
Item 1
Item 2
item 3
item 4
Equipment List Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Work Comp
Work Comp Schedule
Rows
Class Code
# of employees
Total Payroll
Class Code
Class Code
Class Code
Class Code
Use the VIAA Work Comp excel sheet in teams and upload here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Business Narrative
Please provide a short business narrative:
Please attach any of the following here: Dec Pages, Loss Runs, Important Info:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: