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Please Fill out the below so our Agents can assist in putting together a Commercial Insurance Quote or Renewal for your business
Name
*
First Name
Last Name
Email
*
hello@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Type
*
Please Select
Limited Liability Company (LLC)
Sole Proprietor
Corporation
Partnership
C-Corp
S-Corp
Non-Profit
Cooperative (Co-op)
Joint Venture (JV)
Business EIN or UBI #
*
Employer Identification Number, or Unified Business Identifier
Business Name
*
As filed with State or Name if Sole Prop
Year Business Was Established
*
Expiration/Renewal date of current Insurance policy or date you need coverage in place by
*
-
Month
-
Day
Year
Date
Business Address (if home-based, put your home address)
*
Street Address
If your Business is located at your Home, put your address in the field above
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Provide a Brief Description of your Business Operations & Anything you may currently be having issues finding coverage for, if applicable
*
Number of Part-Time Employees (Not including Owner)
*
Number of Full-Time Employees (Not including Owner)
*
Gross Annual Revenue
*
Total Annual Payroll (Include Owner Payroll if you want Business Income claims to include Owner in coverage)
*
Do you need Property Coverage for your Building
*
Yes
No
What is the sq Ft of your building?
If you lease, put sq ft shown in lease agreement
Year built
Type of Roof
Please Select
Shake
Tile
Composition Shingle
Flat Rubber
Flat Thermoplastic
Built Up Bitumen
Built Up Modified Bitumen
Built Up Tar Gravel
Metal
Other
Which Insurance Coverages are you looking to secure?
*
Business Owners Policy (BOP)
General Liability (GL)
Commercial Property
Commercial Auto or Hired/Non-Owned Auto
Professional Liability (E&O)
Employment Practices Liability Insurance
Product Liability
D&O Directors & Officers Coverage
Inland Marine (In-transit Coverage)
Cyber Insurance
Umbrella Coverage
Crime
Stop Gap for L&I - (Or Work Comp if outside WA)
Surety / Bonds
Other
Any Claims in the last 5 years?
*
Yes
No
Claim Date
-
Month
-
Day
Year
Date
Claim Description (If more than one claim, please note all claims & dates & amounts paid in this field below) For the last 5 years
Total Amount Paid or Reserved
Current Insurance Carrier (put None if None)
*
Insurance Renewal Date or Proposed Date if making a shift mid-term
*
-
Month
-
Day
Year
Date
Referring Farmers Agent
*
Enter the name of the Farmers Agent you've been working with or who sent you the link to this form
If you have any questions, please detail below and you will be contacted by one of our Business Insurance Agents within 48 hours after submitting this form
Current Policy Docs (please attach)
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