Business Insurance Quote Form

Contact Information

Before we talk about insurance, please tell us the best ways to reach you.
Name of Primary Contact*

First NameLast Name
Email Address*
example@example.com
Primary Contact Cell Phone Number*
Please enter a valid phone number.
Can we send text messages to this phone number? (By selecting yes, you are opting to receive text messages from iPROTECT) *

YesNo
Can we send text messages to this phone number? *
(By selecting yes, you are opting to receive text messages from iPROTECT)
How did you hear about us?*

Referred by someoneGoogle/Online SearchSocial MediaI was contacted by your agencyOther
GREAT! We LOVE referrals! Who referred you to us?

Types of Business Insurance

Please select the types of business insurance we can help you with.
Policy Types:*

Business AutoCommercial PropertyBusiness General LiabilityCommercial UmbrellaWorkers CompensationOther

General Business Information
Formal Business Name:*
(As it appears on taxes)
Business Entity Type*
SSN associated with business
FEIN
Are there any additional DBA business names?

YesNo
Please list all DBA names and explain their usage:
Business Website:
(Leave blank if no website)
Business Phone Number:
Please enter a valid phone number.
Please list all business owners: (List Primary Contact FIRST)*
Date of Birth:*

MonthDayYear
Date
Mailing Address :*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Is this also your Residential Address?

YesNo
Below, please provide the full name, residential address, and date of birth for the primary contact associated with the LLC. This is used by some carriers to apply up to a 15% credit on quotes.
Annual Gross Sales:*
% of sales to commercial customers
(commercial customers = other businesses)
Total Annual Payroll:*
Number of Full-Time Employees:*
Number of Part-Time Employees:*
Does the business use subcontractors?

YesNo
Total annual cost of subcontractors:
Do you collect certificates of insurance from all subcontractors?

YesNo
Estimate of total Number of subcontractors:

General Business Information
Date business began:*

DayMonthYear
(Date your Business was born)
Years of industry experience:*
(How long have you been working in this type of Business?)
Please describe the nature of the business:*
(Tell us about your business!)
Primary Business Location*

Street Address

Street Address Line 2

CityState

Zip Code
Are there additional business locations?

YesNo
Please list all additional business locations below:*

Does your business currently have Business Auto Insurance?*

YesNo
Please explain below why you do not currently have Commercial Auto Insurance:
If possible, please upload a copy of your current Commercial Auto Insurance policy:

Cancelof
Current Insurance Carrier:*
(Type N/A if unsure)
Current Expiration Date:
(If unsure, please make an educated guess)
Current Expiration Date:

MonthDayYear
(If unsure, make an educated guess)
Number of years with current insurance carrier
Has your business filed any Business Auto Insurance claims within the past 3 years?

YesNo
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):

Please select your desired coverage amounts below.
Combined Bodily Injury/Property Damage Liability
Uninsured/Underinsured Motorists
Medical Payments
Are your business vehicles wrapped OR business information listed on the exterior?*
Please list all vehicles:*
Please list all drivers:*

Does your business currently have Commercial Property Insurance?*

YesNo
Please explain below why you do not currently have Commercial Property Insurance:*
If possible, please upload a copy of your current Commercial Property Insurance policy:

Cancelof
Current Insurance Carrier:
Current Expiration Date:
(If unsure, please make an educated guess)
Current Expiration Date:

MonthDayYear
Date
Number of years with current insurance carrier*
Has your business filed any Commercial Property Insurance claims within the past 3 years?*

YesNo
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):*

Business Personal Property:*
(Also known as business contents) The things you need to run your business.
Business Income / Extra Expense:*
This coverage pays for non-ordinary expenses resulting from business disruption during a claim. If you aren't sure, feel free to go with the pre-selected amount.
Business Inventory:*
This is coverage for items, component parts and raw materials that a company either sells or uses in production.
Equipment used at job sites:*
This is coverage for tools and equipment used on job sites away from the locations owned or operated by the business.
Buildings

Using the section below, please separately list & describe each building that needs to be insured.
Does the business own any buildings that need to be covered by this policy?*

YesNo
Using the section below, please separately list & describe each building that needs to be insured.*

Does your business currently have Commercial Liability Insurance?*

YesNo
Please explain below why you do not currently have Commercial Liability Insurance:*
If possible, please upload a copy of your current Commercial Liability Insurance policy:

Cancelof
Current Insurance Carrier:
Current Expiration Date:
(If unsure, please make an educated guess)
Current Expiration Date:

MonthDayYear
Date
Number of years with current insurance carrier*
Has your business filed any Commercial Liability Insurance claims within the past 3 years?*

YesNo
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):*
Please select the types of Commercial Liability coverage you need:*

General LiabilityProfessional Liability (E&O)Directors & Officers LiabilityEmployment Practices LiabilityLiquor Liability
General Liability Limits:*
If you aren't sure, feel free to go with the pre-selected amount.
Professional Liability (E&O) Limits:*
If you aren't sure, feel free to go with the pre-selected amount.
Directors & Officers Liability Limits:*
If you aren't sure, feel free to go with the pre-selected amount.
Employment Practices Liability Limits:*
If you aren't sure, feel free to go with the pre-selected amount.
Liquor Liability Limits:*
If you aren't sure, feel free to go with the pre-selected amount.

Commercial Umbrella Insurance provides an extra layer of liability protection by covering costs that go beyond your other liability coverage limits
Does your business currently have Commercial Umbrella Insurance?*

YesNo
If possible, please upload a copy of your current Commercial Umbrella Insurance policy:

Cancelof
Current Insurance Carrier:
Current Expiration Date:
(If unsure, please make an educated guess)
Current Expiration Date:

MonthDayYear
Date
Number of years with current insurance carrier*
Has your business filed any Commercial Umbrella Insurance claims within the past 3 years?*

YesNo
Please provide details regarding those claims (approximate dates, cause of damage, approximate amount paid, etc.):*
Desired Excess Liability Limits:*
If you aren't sure, feel free to go with the pre-selected amount.
Desired Retained Limit:*
This works like a deductible

Does your business currently have Workers Compensation Insurance?*

YesNo
Please explain below why you do not currently have Workers Compensation Insurance:*
If possible, please upload a copy of your current Workers Compensation Insurance policy:

Cancelof
Current Insurance Carrier:
Current Expiration Date:
(If unsure, please make an educated guess)
Current Expiration Date:

MonthDayYear
Date
Number of years with current insurance carrier*
Has your business filed any Workers Compensation Insurance claims within the past 3 years?*

YesNo
Please provide details regarding those claims (approximate dates, cause of claim, approximate amount paid, etc.):*

Would you like to include the business owners/officers in this Workers Compensation coverage?*

Yes, include owners/officersNo, exclude owners/officers
Current Experience Modification:
(if known)

Please indicate the number of employees and the percentage of total payroll for each job classification below.*

	Number of Employees	Percentage of Total Payroll
Clerical Staff
Service Staff
Technical Staff
Management Staff

Would you like to include coverage for Employer's Liability?*

YesNo
Employer's Liability Coverage Limits:*
If you aren't sure, feel free to go with the pre-selected amount.

You selected "Other" as the type of insurance you need.

Please tell us below what kind of insurance you're looking for.

Comments

Please use the box below to provide any additional details that may help us find the best insurance options for your business.
Should be Empty:

Contact Information

Types of Business Insurance

General Business Information

General Business Information

Please select your desired coverage amounts below.

Buildings

Commercial Umbrella Insurance provides an extra layer of liability protection by covering costs that go beyond your other liability coverage limits

You selected "Other" as the type of insurance you need.

Comments