Business Insurance Quote Form
Company Name
*
Company Name
Owner Name
*
First Name
Last Name
Owner Date of Birth
*
-
Month
-
Day
Year
Date
Detailed description of your business operations
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policies needed:
*
General Liability
Property (equipment/inventory, etc)
Commercial Auto
Garagekeepers
Workers Compensation
Excess/Umbrella
Cyber
Other
Email
*
Email
Phone Number
*
Number of years in Business:
*
Federal Employer ID Number (FEIN)
Is building owned or leased?
*
Owned
Leased
Home Based
Vehicles to be insured:
Drivers to be insured, Including Driver's License numbers:
Desired coverages:
*
Estimated Annual Payroll & # of employees
*
Estimated Gross Revenue
*
Value of Business Personal Property (Items at your office/warehouse - do not leave facility) that you want insured.
*
Value of Inland Marine Items (tools/equipment, etc. that leaves the premise)
*
Current Dec pages/Loss Runs (OPTIONAL but recommended)
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How many Certificates of Insurance (COI's) do you require per year?
*
Please Select
0
1-5
5-10
10-20
20+
Current Insurer
*
Current Policy Number
*
What insurance carriers have you already been quoted with (so we don't spend time quoting through them again)
*
Any losses/claims in the last 5 years?
*
Yes (please describe below)
No
How did you hear about us?
*
Please Select
I am a current client of yours
Referred by one of your clients
Google
Facebook
BNI
Another agent (Farmers, Allstate, etc)
Any other comments/info
*
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