Commercial Insurance Quote Date Date Format: MM slash DD slash YYYY Referred By:Business NameBusiness PhoneBusiness FaxEntity TypeLLCInc.Ltd.Co.PartnershipSole ProprietorOtherYears in businessYears of Management Experience for Owner(s)FEIN / TAX IDEmail Address Business Website Address ContactsContact Person First Last DOB Date Format: MM slash DD slash YYYY SSNOwner 1 First Last DOB Date Format: MM slash DD slash YYYY SSNOwner 2 First Last DOB Date Format: MM slash DD slash YYYY SSNOwner 3 First Last DOB Date Format: MM slash DD slash YYYY SSNLocations / BuildingsBusiness Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Physical Locations Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Own or Lease Location / BuildingOwnLeaseYear BuiltSquare Footage you OccupySecurity Alarm?YesNoCentral or LocalCentralLocalFire Alarm?YesNoCentral or LocalCentralLocalMonitored 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?IncludedExcludedPlease describe your Business Operations in DetailCurrent Insurance CarrierExpiration DatePolicy #Employees# of Part Time EmployeesEmployees paid by?W21099# of Full Time EmployeesEstimated Payroll for next 12 monthsEstimated Sales / Revenues for next 12 monthsAny Work Subcontracted?YesNo% Payroll for subsUn-Insured Subs Used?YesNoDescribe 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?YesNoPlease list details below such as date of claim, amount paid & description
