Business Quote Request

1
Business Owner Name* This field is required.
First Name
Last Name
2
What is the Name of your Business?* This field is required.
3
Do you have a DBA?Please Include - Corp, Inc, or LLC if Applies if you do not have one please skip.
4
What Year did your Business Open?
5
What Type(s) of Quotes are you Requesting?* This field is required.Select All That Apply
General Liability
BOP / Property
Commercial Auto
Workman's Comp
Commercial Umbrella
Inland Marine (Personal Property)
Professional Liability
Commercial Construction Bond
6
Please Describe Your Line of BusinessEnter a brief description of your type of work.
7
How many Owners, Partners, or Officers apply to your business?Do Not include Employees or Subcontractors
8
What is the Gross Sales/Receipts of the Business* This field is required.This number is before taxes. If this is a new venture please estimate what you believe you may make in the first year.
9
How many Full Time Employees do you have?* This field is required.Do Not include Owners, Officers, Partners, or Subs
10
How many Part Time Employees do you have?Do Not include Owners, Officers, Partners, or Subs
11
What is the Total Gross Employee PayrollIf new venture please estimate what you may pay for the first year. If you do not have any employee please skip this section.
12
Do you Require your Subcontractors to be Insured?Please choose which one applies to your business.
I don't use subs
I use subs and they are insured
I don't hire subs myself
I use subs but they are not insured
13
Do you have current Commercial Lines coverage?* This field is required.
YESNO
14
Have you had any losses in the past 5 years?* This field is required.
YESNO
15
General Liability (GL) Limit NeededIf you need professional liability you can still answer this question.
Please Select
Please Select
None
$500K
1 Mil
2 Mil
3 MIl
4 Mil
5 Mil
16
Commercial Umbrella Limit NeededIf you are not interested in a Commercial Umbrella please skip this question
Please Select
Please Select
None
1 Mil
2 Mil
3 MIl
4 Mil
5 Mil
10Mil
17
Is any work, deliveries, or services done away from your location?* This field is required.This would be anything done outside of your business location.
Yes
No
We have a outside vender for that
We will be starting to shortly
18
What is your work or service area radius?If you answer Yes to the previous question please fill this section out.
0-50
50-100
100-200
200-300
All of Texas
Texas, and Oher States
19
How many Commercial Vehicles are you wanting to Insured?If you do not want a commercial auto quote, please skip or enter 0.
20
How many Drivers will need to be listed on your Auto?If you do not want a commercial auto quote, please skip or enter 0.
21
Do you share a space with another business?* This field is required.
YESNO
22
Do you store any inventory, products, or property at a different location?* This field is required.
YESNO
23
What is the square footage of your office?Even if you work from home please let us know the home square footage.
24
What is the Best Time of Day to Reach You?* This field is required.Let us know the best time to call you if we have questions, or to go over the quote with you.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
25
I AGREE TO RECIEVE A QUOTE FROM A LISCENSED AGENCY WORKING FOR THE RACHEL WEST AGENCY BASED ON THE INFORATION PROVIDED ABOVE. I, AS THE BUSINESS OWNER, PARTNER, OR MANAGER HAVE AUTHERAZATION TO PROVIDE THIS INFORMATION!* This field is required.
Yes
No
Should be Empty: