Business Quote Form

SUITABLE
3001 Motley Dr. Suite L
Mesquite, TX 75150
972-880-7152
Business Quote Sheet
Applicant Information
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Effective Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email:
example@example.com
Company Name:
FEIN/ITIN#:
# of Owners:
Direct Contact:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address:
Phone Number:
Format: (000) 000-0000.
Description of Operations:
Years in Business:
Years of Experience:
Annual Sales:
Annual Payroll:
% Sub-Contract:
# of Employees:
Currently Insured?
Prior Carrier?
Premium:
Claims made in the past 3 years?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Amount Paid $
Do you Have Loss Runs?
Upload Loss Runs

Cancelof
Has coverage ever been canceled/ non-renewed?
Why?
Do you offer Health Plans:
Do you have a safety Program?
Describe
Coverage Needed

Choose Below
General Liability?
Business Liability Limit (in 000's)
General Liability Extension Endorsement?
Additional Insureds? if so List it below:
Waiver of Subrogation:
Retroactive Date:
Contract Requirements?
Upload Contract requirements such example of COI's

Cancelof
Professional Liability?
Professional Liability Limit:
Professional Liability (Type): Errorr and Ommission?
Umbrella/ Excess Liability?
Which coverage(s) would you like excess coverage for? GL, WC, Auto or All Three?
LIABILITY LIMIT:
Inland Marine Coverage / Tools Coverage?

Tools

Does your Equipment move from job to job?
Do you have property in your possession that belongs to others? (Property of Others Coverage)
Do you have miscellaneous tools (Value under $1000 you wish to insure? if so total Value?
Do you leave uninstalled material on a job site?
Do you Rent/Lease equipment (Loss Payee)?
Do you have possession of property belonging to others that you are repairing/moving?
3001 Motley Dr, Suite I I Mesquite, TX 75150 I 972-880-7152 I support@suitableins.com I www.suitableins.com

Business Quote Sheet