PRL BUSINESS INSURANCE QUOTE

1

TELL US THE BUSINESS NAME* This field is requiredPlease give us the legal business name

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2

TELL US THE BUSINESS ADDRESS* This field is requiredjust start typing and we'll do the rest

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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3

TELL US A LITTLE ABOUT YOUR BUSINESS

Partners / owners

Legal Entity

Full -time employees

Years in business

Years of owner experience within industry

Part-time employees

Annual revenue

Annual Payroll

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4

DOES YOUR BUSINESS HAVE SUBCONTRACTORS?

YESNO

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5

DESCRIBE YOUR BUSINESS* This field is requiredGive us the SIC code if known - not to worry we can always find it for you

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6

IS THIS A ONE-TIME OR SEASONAL BUSINESS OR EVENT?

YESNO

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7

DO YOU HAVE ANY SUBSIDIARY BUSINESS?How many?

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8

COMMON COVERAGESSelect one or more coverages - not to worry if you don't see what you need we can help you find it.

Commercial Auto

Business Owners Package Policy (BOP)

General Liability

Workers Compensation

Other types of coverage not listed

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9

DESRIED AMOUNT OF GENERAL LIABILITY COVERAGEEnter the dollar amount you desire

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10

OTHER COVERAGE TYPESPlease tell us other coverage you desire

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11

COMMON TYPES OF ADDITIONAL COVERAGESelect below additional coverage you're interested in

Commercial property

Professional liability (E&O)

Directors & Officers liability

Commercial crime

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12

TELL US YOUR NAME* This field is required

First Name

Middle Initial

Last Name

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13

IS YOUR MAILING ADDRESS THE SAME AS THE BUSINESS

YESNO

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14

MAILING ADDRESSJust start typing and we'll take it from there

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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15

HOW CAN WE CONTACT YOU?* This field is required

Daytime phone

Evening phone

Please enter your email

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16

ADDITIONAL QUESTIONS OR COMMENTS

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17

INNER OFFICE ROUTING

example@example.com

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18

By submitting this form, you acknowledge PRL Insurance could and may access consumer report information such as claims histories and credit-based insurance scores where permitted by law to determine the premium you pay for insurance coverage.

Your insurance score uses information from your credit report to help predict how often you're likely to file a claim, and how expensive those claims will be. When we access your credit-based insurance score, it has no impact on your credit rating.

Both your personal information and insurance score are kept confidential and secure, and will not be resold or redistributed.

We may also submit your information to an authorized third party to obtain and prefill information about your property for you to confirm when you complete the quote request application. By no means does this form consititute a contract for binding insurance. There are additonal types of insurance that may be applicable to your business. We will contact you to gather further information.

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