State 28 Insurance - Quote Request

State 28 Insurance - Quote Request

Request an insurance quote from State 28 Insurance and Safety LLC. Coverage is not bound by submitting this form. Please do not include Social Security numbers, payment card details, passwords, or medical information. Agency NPN 22297346.
Contact and Coverage Request
What do you need insured?
Applicant full name

First NameLast Name
Applicant date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current personal carrier
Personal policy renewal date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal claims in the last 5 years
Contact title / role
Business name
Repeat or update the legal business name below if it differs from the named insured.
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Drivers (driver license numbers optional)
Vehicles
Desired auto liability limits and deductibles
Mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred contact method (for responding to this request only)
Best time to contact (Central Time, America/Chicago)

Hour Minutes

AM/PM Option
Desired effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What personal coverage do you want quoted?
What do you want quoted?
Your selections are requests for agent review and do not guarantee market availability.
If you selected Other / Not sure, please explain
Business Basics and Locations
Legal Business Name
DBA / Trade Name
FEIN (if applicable)
Business Entity Type
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Physical Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Website
Business Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Years in Business
Owner Industry Experience (Years)
Detailed Description of Business Operations
NAICS or Class Code (if known)
Estimated Gross Revenue for the Next 12 Months
Total Annual Payroll
Full-Time Employee Count
Part-Time Employee Count
Owners and Officers
States of Operation

Other
Property address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Homeowners or dwelling details: year built, square footage, construction, roof age/type, electrical/plumbing/HVAC updates, protective devices, mortgagee
Renters or condo contents value
Desired umbrella limit
Underlying policies, carriers, and limits
Estimated Annual Subcontractor Costs
Do You Require Subcontractors to Provide Certificates of Insurance?
Business Locations Schedule
Current Policies Schedule
Has Any Business Policy Been Cancelled, Nonrenewed, or Lapsed?
Losses in the Last 5 Years (leave empty if none)
Desired Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Desired Coverage Limits
Contractual Coverage Requirements (including additional insureds, waiver of subrogation, or primary and noncontributory wording, if applicable)
Business Property, BOP, and General Liability
Business operations and estimated revenue by activity
Operational exposures
Location details (year built, square footage, stories, roof type and age, system updates, fire and security protections)
Building construction type
Estimated building replacement value, business personal property, equipment, and inventory values
Business income coverage need
Requested general liability limits (per occurrence / aggregate)
Requested property deductible
Products/completed operations, liquor exposure, customers or additional insureds, and contract requirements
Estimated value of tools and mobile equipment, if applicable
Commercial Auto and Trucking
Vehicle Schedule
Driver Schedule
Commercial driver license numbers and issuing states/countries (optional)
For each driver, list the full name, driver license number, and issuing state or country. Do not provide Social Security numbers. You may leave this blank and arrange secure follow-up.
Vehicle Use
Additional Auto Needs
USDOT and MC Numbers (if applicable)
Commodities Hauled and Cargo Values
Operations and Filings
Requested Coverage and Prior Insurance
Workers Compensation
Payroll Schedule by State, Location, and Job Duties
Owners and Officers Inclusion Preference
Experience Modification Factor, if known
Experience Modification Effective Date, if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Prior Carrier, Policy Dates, and Premium
Are 3–5 Years of Loss Runs Available?
Safety Program
Subcontractors, 1099 Workers, Uninsured Subcontractor Costs, and Leased or Temporary Employees
Requested Employer Liability Limits
Professional Liability, Cyber, and Commercial Umbrella
Professional services and operations
Professional revenue by service
Professional licenses and years of experience
Contractual liability limits required
Prior professional liability retroactive date, if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Prior professional liability claims or known circumstances
Cyber website, domains, annual revenue, and approximate customer or record count
Types of sensitive data handled (categories only; do not provide actual records)

Other

Flood property address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Flood occupancy and building details
Flood requested limits
Current flood carrier and renewal date
Prior flood losses
Prior cyber incidents, requested cyber limits, and preferred retention
Desired commercial umbrella or excess limit
Motorcycle, boat, or RV schedule
Operators
Desired motorcycle, boat, or RV coverage
Other personal coverage description
Underlying general liability, auto, and employers liability carriers, limits, and policy dates; operations and prior umbrella claims (refer to supplied schedules rather than duplicating them)
Commercial Flood - Business Property
Flood Property Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business building or tenant occupancy
Building Details (Type, Year Built, Floors, Foundation, Basement, and Enclosure)
Estimated Building Replacement Value
Requested Building and Contents Limits and Deductibles
Current Flood Insurer and Policy Expiration Date
Prior Flood Losses (Dates and Details)
Known Flood Zone and Elevation Certificate Information
Is Flood Coverage Required by a Lender?
Documents, Notes, and Consent
Consent to contact and share information

I request that State 28 Insurance and Safety LLC contact me about this request and share the personal and/or business information I provide with First Connect, insurers, and underwriting partners as reasonably necessary to obtain and service insurance quotes. I understand this request is not a binder, policy, or guarantee of coverage, availability, eligibility, or price, and coverage begins only after insurer acceptance and binding confirmation. I confirm I am authorized to provide this information.
Current declarations pages and supporting documents (optional)

Upload declarations pages, schedules, or supporting documents. Redact Social Security numbers, bank/payment details, passwords, and unnecessary personal information.
Cancelof
Anything else we should know? Please do not enter sensitive identifiers, payment details, passwords, or medical information.
Authorization and acknowledgment for insurance quoting and underwriting

For insurance quoting and underwriting, I authorize State 28 Insurance and Safety LLC and prospective insurers, as permitted by applicable law, to verify information and obtain relevant underwriting reports and insurance loss history. I understand that additional carrier-specific applications, notices or authorizations may be required. This request is not a binder, policy, or guarantee of coverage, availability, eligibility, or price; coverage begins only after an insurer or authorized agent confirms binding.
Do not submit another person’s information without permission. Do not provide Social Security numbers, payment information, passwords, or medical information. Driver license numbers are optional; provide driver details only for requested auto or recreational coverage. Separate driver or carrier authorizations may be required.
Should be Empty:

Rows	Yes	No	Unknown
Multi-factor authentication enabled
Backups maintained
Data encrypted
Security training provided

State 28 Insurance - Quote Request

Contact and Coverage Request

Business Basics and Locations

Business Property, BOP, and General Liability

Commercial Auto and Trucking

Workers Compensation

Professional Liability, Cyber, and Commercial Umbrella

Commercial Flood - Business Property

Documents, Notes, and Consent