Commercial Quote
General Liability, Business Owner Policy, Workers Compensation, Commercial Auto, Professional Liability/ E&O, Cyber Liability, Commercial Property.
Customer Details:
Full Legal Business Name:
*
DBA (if applicable):
FEIN:
*
Business Type:
*
Please Select
LLC
S-Corp
C-Corp
Sole proprietorship
Nonprofit
Unsure
Business Owners Name
*
First Name
Last Name
Business Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Owners Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Email
*
example@example.com
Owner Email
*
example@example.com
Physical Business Address:
*
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
Description of Operations:
*
Estimated Annual Gross Revenue
*
Number of Full-Time Employees
*
Number of Part-Time Employees
*
Do you use subcontractors:
*
Yes
No
Other
Do you currently have insurance?
*
Yes
No
Other
If Yes, List current carrier(s) and amount:
Any insurance claims in the past 5 years?
*
Yes
No
Other
What type(s) of commercial coverage are you interested in?
*
General Liability
Workers Compensation
Business Owner policy
Auto
Cyber
Professional Liability
Property
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General Liability (GL)
Location Square Feet:
*
Do clients or customers visit your premises?
*
Yes
No
Other
Do you perform any work off-site?
*
Yes
No
Other
Estimated number of certificates of insurance needed annually?
*
Any specialized equipment or operations?
*
Required Coverage Limits (if known)
*
Are you required to name others as additional insureds?
*
Yes
No
Other
If so, please provide their information
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Workers' Compensation
Total Annual Payroll
*
Breakdown of Payroll by Job Type:
*
If you would like to upload, please state in the text box and below upload the file
Do you want to include or exclude business owner(s)?
*
Please Select
Include
Exclude
Undecided
Any employees working out of state?
*
Yes
No
Other
Any workplace safety programs in place?
*
Yes
No
Other
Any prior workers' comp claims?
*
Yes
No
If answered yes to claims, please explain:
If you would like to upload the file, please state that in the text box
File Upload
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Business Owner's Policy (BOP)
Do you own or lease the business property?
*
Please Select
Own
Lease
Rent
Other
Building Info (Year built, construction type, etc.)
*
If you would like to upload the file, please put that in the text box.
Building Value (if owned)
*
Business Personal Property (equipment, inventory, etc.)
*
Safety Systems?
*
Fire
Alarm
Security
Other
Any tentants or shared space in the building?
*
Yes
No
Other
File Upload
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Commercial Auto
Number of Business Vehicles
*
Vehicle Info: Year, Make, Model, Vin (for each)
*
If you are going to upload, please state in the text box above
Garaging Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vehicle Use Type
*
Please Select
Deliveries
Sales
Service
Multiple Use
Driver Info: Name, DOB, License #)
*
If going to upload, please state in the text box above.
Any personal use of the business vehicles?
*
Yes
No
Other
Any accidents or violations in the last 3 years?
*
Yes
No
Other
File Upload
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Professional Liability / E&O
Industry/Profession
*
Services Provided
*
Do you provide any of the following?
*
Client Data
Legal
Advice-Based
Other
Desired Coverage Amount:
*
Any prior E&O claims?
*
Yes
No
Other
Explain if yes:
*
File Upload
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Cyber Insurance
Do you collect/store sensitive customer information?
*
Yes
No
Other
Do you process credit cards or financial data?
*
Yes
No
Other
Do you store data in the cloud or on a local server?
*
Please Select
Cloud
Local
Unknown
Other
Do you have a cybersecurity protocols in place?
*
Yes
No
Other
Any known breaches or incidents in the past?
*
Yes
No
Other
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Commercial Property
Standalone
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Own or lease the building?
*
Please Select
Own
Lease
Other
Building Info: Year built, Sq ft, Construction type:
*
If you would like to upload a file, please state in the text box.
Building Value
*
Value of Business Personal Property:
*
Contents
Any updates on the following?
*
Electrical
Plumbing
Roof
Hvac
Other
Security features in place?
*
Yes
No
Other
File Upload
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Submission
Additional Notes or Questions?
*
Best Time to Contact You:
*
Best Way to Contact You:
*
I authorize Royal Palms Group to collect this information for the purpose of providing a quote.
*
Yes
No
File Upload (if applicable):
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Should be Empty: