Commercial General Liability and Workers Comp Quote Sheet
Please complete the form below to receive a free, no-obligation commercial insurance quote. Once your quote has been prepared, a member of our team will contact you to review your coverage options and answer any questions.Thank you, The Christopher Leibel Agency
Type of Insurance Needed
General Liability
Workers Comp
Personal Auto/Home Insurance
Business continuation plan
Life Insurance
Tax free retirement/savings
Property
Equipment Coverage
Commercial Auto
Umbrella/Excess
Other
YOUR NAME
*
DATE OF BIRTH:
*
/
Month
/
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
COMPANY NAME:
*
FRANCHISE
*
YES
NO
BUSINESS ENTITY
*
Please Select
INDIVIDUAL
S-CORP
LLC
CORPORATION
DBA:
BUSINESS ADDRESS:
*
FEIN:
*
Continuous insurance coverage for the business?
*
YES
NO
NEW BUSINESS
Description of Business
IMPORTANT COVERAGES DESIRED?
How many Property Additional Interests?
ANY CLAIMS IN THE LAST 3 YEARS?
*
CURRENT INSURANCE COMPANY
*
INSURANCE PRICE/PREMIUM
*
DEDUCTIBLE
*
VALUE OF YOUR CONTENTS?
Year Bus was Established:
*
Years of Experience:
*
Annual Estimated Gross Sales
*
Annual Payroll
*
Full Time Employees
*
Part Time Employees
Do you hire contract employees or pay employees with a 1099?
*
YES
NO
Do you subcontract any work?
*
YES
NO
If Yes, are all subcontractors hired by the applicant required to provide a certificate of insurance?
Please Select
YES
NO
LOCATION
*
Please Select
Stand Alone Building
Strip Shopping Center
Enclosed Mall
Attached to a Habitational structure
Number of stories
*
Construction
*
Please Select
Frame
Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Roof Type
*
Please Select
Composite
Flat-Rubber
Shake
Built-up Bitumen
Tile
Other
BUILDING AGE:
*
Year for Roof/Wiring/Heating/Plumbing
Sprinkler
*
Full
Partial
None
Building Amount
Has the building undergone a comprehensive renovation since it was originally built? ..
*
Yes
No
DONT KNOW
Tenant Improvement and Betterment (value of permanent upgrades you made to the location)
Contents Amount
*
Value of Contractors Tools and Equipment Owned
Do you want insurance on your tools incase it is stolen on a jobsite?
YES
NO
RESTAURANTS
TYPE OF RESTAURANT
Please Select
Fast Food
Casual Dining
Fine Dining
Restaurants - No Cooking/No Frying
Restaurants – Expanded Alcohol Sales
Bars and Taverns
Wine Bars
Brew Pubs – With Commercial Cooking
Brew Pubs – No Cooking
Catering Receipts:
Liquor Receipts:
Liquor License Number:
How many employees are certified in Liquor training?
Total Building Square Footage:
Public Square Footage excluding cooking area and office:
What is the Seating Capacity of Restaurant?:
Banquet Facility Square Footage
Number of fridges
Type of the Extinguishing system that covers hoods, ducts and all cooking equipment:
Please Select
Dry Chemical
Wet Foam
Water Spray
Other
How often is the automatic fire extinguishing system inspected and serviced by a contracted outside firm?
Please Select
Monthly
Quarterly
Semi-Annual
Annual
Never
ENTERTAINMENT
Please Select
None
DJ
Band
Karaoke
Special Events
Video Games
Pinball Machines
Pool Tables
Dart Boards
Two or More TV’s
Gaming Tables
Dance Floor
Foam Machine
Mechanical Rides
Please upload your insurance papers for comparison and accuracy
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