SUITABLE
3001 Motley Dr. Suite L
Mesquite, TX 75150
972-880-7152
Business Quote Sheet
Applicant Information
Today's Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email:
*
example@example.com
Company Name:
FEIN/ITIN#:
# of Owners:
Direct Contact:
*
DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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?
Yes
No
Prior Carrier?
Premium:
Claims made in the past 3 years?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Amount Paid $
Do you Have Loss Runs?
Yes
No
Upload Loss Runs
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Has coverage ever been canceled/ non-renewed?
Yes
No
Why?
Do you offer Health Plans:
Yes
No
Do you have a safety Program?
Yes
No
Describe
Coverage Needed
Choose Below
General Liability?
Yes
No
Business Liability Limit
$500/$1,000,000
$1,000,000/$2,000,000
$2,000,000/$4,000,000
$5,000,000/$10,000,000
General Liability Extension Endorsement?
Additional Insureds? if so list it below:
Waiver of Subrogation? if so list it below:
Retroactive Date:
Contract Requirements?
Yes
No
Upload Contract requirements such example of COI's
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Professional Liability / Errors and Ommissions?
Yes
No
Professional Liability Limit:
$500,000/$1,000,000
$1,000,000/$2,000,000
$2,000,000/$4,000,000
Professional Liability (Type): Errorr and Ommission?
Umbrella/ Excess Liability?
Yes
No
Which coverage(s) would you like excess coverage for? GL, WC, Auto or All Three?
LIABILITY LIMIT:
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Inland Marine Coverage / Tools Coverage?
Yes
No
Tools
Rows
Tools Description
Year
Serial #
Value $
1
2
3
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?
Property Coverage or Business Personal Property?
Yes
No
Building Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Construction:
Frame
Joisted Masonry
Non-Combustible
Masonry NC
Fire Resistive
Year Built:
Updates: Roof:
Plumbing Updates:
Electrical Updates:
Heating Updates:
Total Sqft:
Occupied Sqft:
Other Occupants:
Sprinklered:?
Yes
No
Alarm:
Burglar
Fire
Central Station
Other:
#of Stories:
Value $:
Basement:
Protection Class:
Business Personal Property / Contents Only
Yes
No
Business Personal Property Coverage Amount$:
Business Personal Property of Others Amount $:
Ordinance or Law Coverage:
Coverage A: The value of the undamaged portion of a damaged building.
Coverage B: Demolition costs relating to the undamaged portion of the building or structure.
Coverage C: Increased cost of construction due to updated codes.
Property Off Premises:
Transportation:
Spoilage coverage. When power outages ruin perishable items:
Property Extension Endorsement:
Deductibles
$500
$1,000
$5,000
Flood?
Yes
No
Workers Compensation?
Yes
No
FEIN/SS#:
States Covered:
Employers Liability Limit (in 000s):
$100/$500/$100
$500/$500/$500
Type a question
Rows
Employee /Owner
Job Describtion
Part Time/ Full Time
Bate of Birth
Included or Excluded
1.
2.
3.
4.
5.
Submit
Should be Empty: