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?
Property Address

Street Address

Street Address Line 2

CityState

Zip Code
Your E-mail Address
Do you have a website?
Website URL
Preferred Contact?
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?

Annual Payroll
Does the business own any autombiles?
Do you sub-contract work to others?
Type / Percentage of Subcontracted work
Prior Insurance Information
Do you currently have insurance, or have you had it in the past?
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?
Has coverage been Canceled / Non-Renewed / Declined in the past three years?
Why was your policy cancelled?
Any Claims in past (5) years?
If yes, please specify Date, Amount Paid and Description of each loss-claim
Do you want coverage for your business property (tools and equipment)?
Do you want coverage for your Building?
Protection Class (if known)
Building within 1,000 feet of hydrant?
Building within 3 miles of fire station?
Year Built
Number of Stories
Construction
Desired Coverage Information / Amounts
Liability Limit Desired
Building Coverage Limit
Business Property LImit
Deductible
Do you have an alarm system?
What type of fire protection / alarm system?
Notes
Insured Name

First NameLast Name
Policy Effective Date

MonthDayYear
Submitted by

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

Upload a File

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Once policy has been sold obtain following Documentation:
Amend task to Priority "Inbox" assign to ASTRID
Set up policy in Prime
Amend task to Priority "Inbox" assign to @ Daily
Amend task to Priority "NEW BUSINESS" assign to Pending new business
Should be Empty:

Rows	# of
Full Time
Part Time

Business Information

Prior Insurance Information

Desired Coverage Information / Amounts