Commercial Insurance Quote Form

 

Contact Information:

 
First Name Insured
 
Address 1
Address 2
City
State
Zip Code
First Named Insured Phone
Effective Date / /
Expiration Date / /
State of Domicile
Federal Employer ID
Business Website
Email
 
 

 

Underwriting Information:

 
Do the Applicant's Annual Receipts and/or combined building plus personal property values at any one location exceed $3,000,000?

Yes     No
Do the Applicant's Annual Receipts and/or combined building plus personal property values at any one location exceed $15,000,000?

Yes     No
At any location, does the Applicant both occupy a portion of the premises and lease 50% or more of the premises (excluding basement) to others?

Yes     No
What is the annual Payroll?
What is the percentage of subcontractors used?
 
 

 

Product Information:

 
Agency Name
Policy Product
Policy Program
Business Type
Full Time Employees
Part Time Employees

 

Year Business was Established or Acquired by Current Owner
Select Lines of Business to be Included in this Policy
Property        General Liability
Automobile    Umbrella
Continuous Policy

Yes          No
Does applicant have any prior insurance?

Yes          No
Have there been any claims or occurrences within the last 5 years?

Yes          No
Do you have a hard copy loss runs?

Yes          No
Any other named insureds with common majority ownership?

Yes          No
Is the primary location address different from the mailing address?

Yes          No
 
 

 

Prior Insurance:

 

Line Of Business

Prior Policy Exp Date

Prior Carrier

Prior Premium

/ /

/ /

/ /

Has the applicant ever had coverage cancelled or non-renewed?

Yes          No
 

 

Policy Limit / Deductible Information:

 
Personal Property Valuation
Blanket Coverage
Building Blanket
Personal Property Blanket
GL Occurrence/Aggregate Limit
Products and Completed Operations Aggregate
Personal and Advertising Injury Limit
Tenants Legal Liability Limit
Medical Expenses
 
 

 

Property Location Schedule:

 

                                        Location 1
Address
Address 2
City
State
Zipcode
County
Territory
Protection Class
Interest Type
Is the distance to the fire station less than 5 miles?

Yes          No
Is the property within 1000' of commercially navigable body of water?

Yes          No
Detailed Description of Operations
 
 

 

Building Schedule:

 
Building Limit
Personal Property Limit
Building Valuation
Construction Type
Year Built
Total Area - All Floors excluding Basement
Number of Stories
Number of Basements
Less than 1000' from hydrant?

Yes          No
Does building have sprinklers?

Yes          No
Fire Alarm Type

Central Station  Local  None
Burglar Alarm Type

Central Station  Local  None
Any loss payees/mortgagees?

Yes          No
 
 

 

Additional Buildings:

 
Is there another location?

Yes          No
Describe
 
 

 

Property Policy Options:

 

Employee Dishonesty

Signs
 
 

 

Supplemental Application Information:

 
Is applicant a subsidiary of another entity or does the applicant have any subsidiaries?

Yes   No
 
 

 

More Information:

 
 
   

For Auto Quotes

Vehicle One:

Vehicle Two:
Driver Driver
TDL TDL
SS # SS #
DOB DOB
Year Year
Make Make
Model Model
Vin Vin
Tickets Tickets
Accidents Accidents
Claims Claims
Average Miles / Year Average Miles / Year
Average Miles / Week Average Miles / Week
BI /PD BI /PD
Lien Holder Name Lien Holder Name
Phone Number Phone Number