Business Insurance Quote Request
Request for Insurance QuotationComplete Business Information, plus any sections for which you are seeking a quote. Ignore sections for which you do not want coverage quoted.Return by fax or email. Contact information is below. Business InformationName: FORMTEXT ?????Mailing Address: FORMTEXT ?????City, State, Zip: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????Inspection Point of Contact: FORMTEXT ?????Accounting Point of Contact: FORMTEXT ????? FORMCHECKBOX Corp FORMCHECKBOX LLC FORMCHECKBOX Sole PropFEIN or SSN: FORMTEXT ?????Year Started: FORMTEXT ?????Current Insurance Company(s): FORMTEXT ?????Expiration Date(s): FORMTEXT ?????Total Yearly Premium(s): FORMTEXT ?????Street Address Location #1 FORMTEXT ????? Location #2 FORMTEXT ????? Location #3 FORMTEXT ?????What does your business do? Describe all operations: FORMTEXT ?????Additional Named Insureds: FORMTEXT ?????Attach Separately FORMCHECKBOX 5 Year, currently valued Loss Runs. (Ask your existing insurance agent/company for these and they should have them to you within 24 hours. If in business less than five years, send what you have. If no prior insurance, ignore.)Explain any losses over $5,000 FORMTEXT ????? Property FORMCHECKBOX Do Not Quote Attach as many sheets as necessaryLocation #: FORMTEXT ?????Building #: FORMTEXT ?????Insurance Values Building: $ FORMTEXT ????? Contents: $ FORMTEXT ????? Business Income: $ FORMTEXT ????? Miscellaneous: $ FORMTEXT ?????Responding Fire Co: FORMTEXT ?????Distance to Hydrant: FORMTEXT ?????Year Built: FORMTEXT ?????Sq Ft: FORMTEXT ?????Year Updated: Roof FORMTEXT ?????Wiring FORMTEXT ????? Plumbing FORMTEXT ?????Heating FORMTEXT ?????Alarms: FORMCHECKBOX Fire FORMCHECKBOX Burglar FORMCHECKBOX Both FORMCHECKBOX Local Only FORMCHECKBOX Central StationHeat: FORMCHECKBOX Oil FORMCHECKBOX Electric FORMCHECKBOX Other FORMTEXT ?????Sprinklers? FORMTEXT ?????Construction (frame, masonry, etc.) FORMTEXT ?????Roof (metal, composition shingle, etc.) FORMTEXT ?????Siding (metal, vinyl, wood, etc.) FORMTEXT ?????Location #: FORMTEXT ?????Building #: FORMTEXT ?????Insurance Values Building: $ FORMTEXT ????? Contents: $ FORMTEXT ????? Business Income: $ FORMTEXT ????? Miscellaneous: $ FORMTEXT ?????Responding Fire Co: FORMTEXT ?????Distance to Hydrant: FORMTEXT ?????Year Built: FORMTEXT ?????Sq Ft: FORMTEXT ?????Year Updated: Roof FORMTEXT ?????Wiring FORMTEXT ????? Plumbing FORMTEXT ?????Heating FORMTEXT ?????Alarms: FORMCHECKBOX Fire FORMCHECKBOX Burglar FORMCHECKBOX Both FORMCHECKBOX Local Only FORMCHECKBOX Central StationHeat: FORMCHECKBOX Oil FORMCHECKBOX Electric FORMCHECKBOX Other FORMTEXT ?????Sprinklers? FORMTEXT ?????Construction (frame, masonry, etc.) FORMTEXT ?????Roof (metal, composition shingle, etc.) FORMTEXT ?????Siding (metal, vinyl, wood, etc.) FORMTEXT ?????Location #: FORMTEXT ?????Building #: FORMTEXT ?????Insurance Values Building: $ FORMTEXT ????? Contents: $ FORMTEXT ????? Business Income: $ FORMTEXT ????? Miscellaneous: $ FORMTEXT ?????Responding Fire Co: FORMTEXT ?????Distance to Hydrant: FORMTEXT ?????Year Built: FORMTEXT ?????Sq Ft: FORMTEXT ?????Year Updated: Roof FORMTEXT ?????Wiring FORMTEXT ????? Plumbing FORMTEXT ?????Heating FORMTEXT ?????Alarms: FORMCHECKBOX Fire FORMCHECKBOX Burglar FORMCHECKBOX Both FORMCHECKBOX Local Only FORMCHECKBOX Central StationHeat: FORMCHECKBOX Oil FORMCHECKBOX Electric FORMCHECKBOX Other FORMTEXT ?????Sprinklers? FORMTEXT ?????Construction (frame, masonry, etc.) FORMTEXT ?????Roof (metal, composition shingle, etc.) FORMTEXT ?????Siding (metal, vinyl, wood, etc.) FORMTEXT ?????General Liability FORMCHECKBOX Do Not QuoteLimitsPer Occurrence FORMCHECKBOX $1,000,000 FORMCHECKBOX $2,000,000 FORMCHECKBOX Other: $ FORMTEXT ????? Aggregate FORMCHECKBOX $1,000,000 FORMCHECKBOX $2,000,000 FORMCHECKBOX $3,000,000 FORMCHECKBOX Other: $ FORMTEXT ?????Location #1: Yearly Est. Gross Sales: $ FORMTEXT ????? Yearly Payroll: $ FORMTEXT ????? Location #2: Yearly Est. Gross Sales: $ FORMTEXT ????? Yearly Payroll: $ FORMTEXT ????? Location #3: Yearly Est. Gross Sales: $ FORMTEXT ????? Yearly Payroll: $ FORMTEXT ????? Do you currently offer health insurance to your employees? FORMTEXT ?????Business Auto FORMCHECKBOX Do Not QuoteCoverage LimitsLiability FORMCHECKBOX $500,000 FORMCHECKBOX $1,000,000 FORMCHECKBOX $1,500,000 FORMCHECKBOX Other: $ FORMTEXT ?????Uninsured Motorists (UM): FORMCHECKBOX $500,000 FORMCHECKBOX $1,000,000 FORMCHECKBOX $1,500,000 FORMCHECKBOX Other: $ FORMTEXT ?????Underinsured Motorists (UIM) FORMCHECKBOX $500,000 FORMCHECKBOX $1,000,000 FORMCHECKBOX $1,500,000 FORMCHECKBOX Other: $ FORMTEXT ?????Medical FORMCHECKBOX $2,000 FORMCHECKBOX $5,000 FORMCHECKBOX $10,000 FORMCHECKBOX Other: $ FORMTEXT ?????PIP (if available in your state) FORMCHECKBOX $2,000 FORMCHECKBOX $5,000 FORMCHECKBOX $10,000 FORMCHECKBOX Other: $ FORMTEXT ?????Physical Damage Deductible: FORMCHECKBOX $500 FORMCHECKBOX $1,000 FORMCHECKBOX $2,500 FORMCHECKBOX Other: $ FORMTEXT ?????Garaging address (if different than mailing): FORMTEXT ????? Cities where you operate: FORMTEXT ????? Radius in Miles: FORMTEXT ?????Any other vehicles owned but not listed? FORMCHECKBOX Yes FORMCHECKBOX NoComplete and Attach separately: FORMCHECKBOX Driver List (example below) FORMCHECKBOX Vehicle List (example below)Internal Use Only: FORMCHECKBOX 1 Any Auto FORMCHECKBOX 2 All Owned Autos FORMCHECKBOX 7 Listed Autos FORMCHECKBOX 8 Hired Autos FORMCHECKBOX 9 Non-owned Autos Vehicle ListAttach only if quoting Business Auto. Use this form or attach a copy from your existing policy.InsurancePhysical DamageYearMakeModelVINTotal$ ValueSeating Capacity*LiabilityMedicalPIPComprehensiveCollision1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX * Include driver in seating capacity.Driver ListAttach only if quoting Business Auto. Use this form or attach a copy from your existing policy.NameDate of BirthLicense #State Licensed:Years Experience# of Traffic Violations*1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????* Attach MVRs from your fileWorkers’ Compensation FORMCHECKBOX Do Not QuoteCoverage Limits FORMCHECKBOX $100,000/$500,000/$100,000 FORMCHECKBOX $500,000/$500,000/$500,000 FORMCHECKBOX $1,000,000/$1,000,000/$1,000,000Include with this application FORMCHECKBOX Current experience modification worksheet. Only applicable for businesses in operation four years or more. If your state is an NCCI state, obtain yours for free by calling them directly at 800.622.4123.All payroll estimates yearlyOwners / Officer PayrollComplete for any owner / officer with over 5% ownership interest.NameDate of Birth Ownership % Include/Exclude? Payroll Estimate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? $ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? $ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? $ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? $ FORMTEXT ????? Staff Payroll by ClassificationLocation No.What do your employees do?Approx No. of EE'sAnnual Payroll EstimateInternal Use.Class Code1Example 1: Drive forklift. Move wood in lumber yard.4$100,000 FORMTEXT ?????1Example 2: Office / Clerical2$50,000 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????I would like to hear more about insurance for: Umbrella LiabilityCyber Liability/Data BreachBusiness Income With Extra ExpenseInland MarineFloodBoat/Protection & Indemnity/Jones ActTransportationOcean MarineEmployee DishonestyEmployment Practices LiabilityDirectors and OfficersEmployee Benefits LiabilityFiduciary LiabilityHealth – Group or individualLife – Group or individualDisability – Group or individualLong Term Care – Group or individualYes FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX No Thank You FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other Comments/Questions/Information: FORMTEXT ?????Applicant Signature: Date: FORMTEXT ????? ................
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