Commercial Online Quote Intake Form
Business Name
*
Client Name
*
First Name
Last Name
How did you hear about us? Is this a referral?
*
When is this quote needed by?
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business FEIN
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of contact?
*
Call
Text
Email
When did the business start?
*
What type of business is this?
*
What type of quote are they looking for?
*
BOP
GL
Work Comp
Commercial Auto
Other
How many vehicles are there?
Please Select
1
2
3
4
5
6+
List the vehicles below
How many drivers are there?
Please Select
1
2
3
4
5
6+
List the drivers below (Name, DOB, DL if they have it)
What liability limits do they need?
250/500
300csl
500csl
1mil csl
Other
Liability only or full coverage on the vehicles?
Please Select
liability only
comp/coll
comp no coll
What deductible would you like?
Number of Employees
Gross Annual Payroll
Does the Owner want coverage for themselves?
Gross Sales/Receipts
Is the building owned or rented?
owned
rented
Year built
Square foot
# of stories
Structure?
Please Select
wood frame
full masonry
masonry veneer
steel
other
Type of roof
Please Select
shingle
rolled flat
metal
other
When was the roof last updated
Current coverage on the building
deductible
how much BPP is needed (business personal property)
Is the BPP scheduled or a blanket?
Miscellaneous info
Submit
Should be Empty: