Business Form
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General Information
Contact Name *
Business Name
City
Zip
Business Phone
Email*
Address
State
County
Fax
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
CurrentCoverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description
of your business and clientele
Property/Premises Information
Address
Occupancy Status Owner Tenant
Year Built
% Occupied
Sprinklers Yes No
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm Yes No
Building Value
Contents
Other Property (specify)
Insurance Information
Other
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had
in the past 5 years
Additional Comments
* indicates required fields
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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