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General Information
Business Insurance Quote Form
In order for our Agents to provide the best quote possible, please provide as much information as you can.
Go To:
I am looking for:
Business Name:
Contact Name:
Mailing Address:
FEIN:
Business Formation:
Business Phone:
Fax Number:
E-Mail:
Website:
Year Business Estabilished:
Describe Operations:
Owners/Officers/ Partners:
Business Locations:
Do you have an Accountant?
Do you have Employees?
Do you use Subcontractors?
Title/duties:
UCT#
Other Phone:
General Liability
OR
Be Detailed: Include usual daily business operations plus anything that is planned for or is offered in addition to usual tasks.
Name
Title
Annual Salary or Payroll
Duties
Address
Area (SQFT)
# Employees at this location
Annual Gross Payroll (per location)
Annual Gross Sales
(per location)
Describe work performed at this location
If yes: Name of Accountant: Phone #:
If yes:
Name
Annual Gross Payroll
Job Duties
Full or Part Time
If yes select all that apply:
Annual Costs of Sub-Contract Labor including materials:
Currently Insured? :
Claims History:
Limits Requested for quote:
If yes:
Company Name
Policy Number
Effective Date
Expiration Date
Current Limits
If other please enter limits here:
Date
Description
Amount Paid
Business Auto
If yes:
Company Name
Policy Number
Effective Date
Expiration Date
Bodily Injury
If other please enter limits here:
Uninsured Motorist
Personal Injury(PIP)
Comprehensive
Collision
Medical Payments
Property Damage
CSL
OR
Rental
Towing
Date
Description
Amount Paid
Name
Date of Birth
Lic. State
License Number
Job Duties
#
1
2
3
4
5
6
7
8
Currently Insured? :
Current Limits:
Claims History:
Drivers:
Vehicle Information
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:
Vehicle 5:
Year
Make
Model
VIN
How is Vehicle Used?
Year
Make
Model
VIN
How is Vehicle Used?
Year
Make
Model
VIN
How is Vehicle Used?
Year
Make
Model
VIN
How is Vehicle Used?
Year
Make
Model
VIN
How is Vehicle Used?
Business auto quote will be provided using current coverage amounts as provided- unless otherwise instructed. Please provide any additional information or changes you want quoted here:
Commercial Property
Workers Comp
Other
