Commercial Insurance Quote Date MM slash DD slash YYYY Referred By:Business Name*Business Phone*Business FaxEntity Type LLC Inc. Ltd. Co. Partnership Sole Proprietor Other Years in businessYears of Management Experience for Owner(s)FEIN / TAX IDEmail Address* Business Website Address ContactsContact Person First Last DOB MM slash DD slash YYYY SSNOwner 1 First Last DOB MM slash DD slash YYYY SSNOwner 2 First Last DOB MM slash DD slash YYYY SSNOwner 3 First Last DOB MM slash DD slash YYYY SSNLocations / BuildingsBusiness Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Physical Locations Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Own or Lease Location / Building Own Lease Year BuiltSquare Footage you OccupySecurity Alarm? Yes No Central or Local Central Local Fire Alarm? Yes No Central or Local Central Local Monitored ByCoverageMark the coverage(s) you want quote(s) for General Liability Workers Comp Building Business Personal Property Business Auto Equipment Flood Excess Liability Professional Liability Health Life Loss of Income Liquor Liability Other Desired Effective Date for Coverage(s)Do owners want to be Included or Excluded for Workers Comp? Included Excluded Please describe your Business Operations in DetailCurrent Insurance CarrierExpiration DatePolicy #Employees# of Part Time EmployeesEmployees paid by? W2 1099 # of Full Time EmployeesEstimated Payroll for next 12 monthsEstimated Sales / Revenues for next 12 monthsAny Work Subcontracted? Yes No % Payroll for subsUn-Insured Subs Used? Yes No Describe work subcontracted out to Insured SubsRequired for Construction CompaniesPlease enter the percentage of work done for the following:% Residential% Commercial% Industrial% Institutions% New Construction% Repair% Remodel / AdditionsClaim HistoryAny claims in the last 5 years? Yes No Please list details below such as date of claim, amount paid & descriptionCAPTCHA Δ TweetShareSharePin0 Shares
