Business Insurance Quote Request

Page Insurance, Ltd

102 Boston Street

Guilford, CT 06437

(203) 453-5258

info@pageins.com
Source of Business: Where did you get our name?
Effective Date Requested*

MonthDayYear
Your Name*

First NameLast Name
Your Phone Number*

Area CodePhone Number
Business Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is Property Address same as Mailing Address?

YesNo
Property Address

Street Address

Street Address Line 2

CityState

Zip Code
Your E-mail Address
Do you have a website?

YesNo
Website URL
Preferred Contact?*

E-mailPhoneEither Email or Phone
Business Information
Type of Business
FEIN (if you have one)
Description of Operations
Type of Entity
Year Business Started
Number of Years Experience
How many locations do you have?
List other locations
Annual Sales Receipts (Gross)
Square Footage of Shop / Office Space
Do you have any employees?

YesNo

Annual Payroll
Does the business own any autombiles?

YesNo
Do you sub-contract work to others?

YesNo
Type / Percentage of Subcontracted work
Prior Insurance Information
Do you currently have insurance, or have you had it in the past?

YesNo
Current / Previous Insurance Carrier
Types of Policies with Company
Expiration Date of Current policy (if applicable)

MonthDayYear
How long have you been with this company?
Has there been continuous coverage for the past year?

YesNo
Has coverage been Canceled / Non-Renewed / Declined in the past three years?

YesNo
Why was your policy cancelled?
Any Claims in past (5) years?

YesNo
If yes, please specify Date, Amount Paid and Description of each loss-claim
Do you want coverage for your business property (tools and equipment)?

YesNo
Do you want coverage for your Building?

YesNo
Protection Class (if known)
Building within 1,000 feet of hydrant?

YesNoNot applicable
Building within 3 miles of fire station?

YesNoNot applicable
Year Built
Number of Stories
Construction

FrameMasonryOther
Desired Coverage Information / Amounts
Liability Limit Desired

$300,000$500,000$1,000,000
Building Coverage Limit
Business Property LImit
Deductible

$500$1,000$2,500
Do you have an alarm system?

YesNo
What type of fire protection / alarm system?

Smoke AlarmsCentral Station Fire AlarmCentral Station Burglar Alarm
Notes
Insured Name

First NameLast Name
Policy Effective Date

MonthDayYear
Submitted by*

Agency StaffInsuredOther
Agency Staff
Attachments (Policies, Loss Runs, etc)

Upload a File

Cancelof
CLIENT INFORMATION Entered in IntellectQUOTE Task Created in IntellectCreate Folder in Scanned docs
Once policy has been sold obtain following Documentation:

Signed Application, quote, payment etc.Signed Cancellation if applicableSigned Flood Selection / Rejection letter or Quote requestSigned Personal Umbrella Quote Selection / Rejection Form
Amend task to Priority "Inbox" assign to ASTRID
Set up policy in Prime

Create contact in PrimeCreate policy (including the A-Trans)Attach the following document in order: (Most documents can be found in insured folder Scanned docs)--- Information sheet--- property card--- replacement cost calculation--- application(s)--- quote(s)--- Signed application--- Bind request if applicableCopy notes all from intellect to Prime.Delete folder from scanned docs
Amend task to Priority "Inbox" assign to @ Daily
ADD TO ENEWS Task create in Intellect (Priority B, Assign @daily)SEND THANK YOU NOTE task create in intellect (Priority B, Assign @daily)
Amend task to Priority "NEW BUSINESS" assign to Pending new business
Should be Empty:

	# of
Full Time
Part Time

Business Information

Prior Insurance Information

Desired Coverage Information / Amounts