Business Quote

General Info
Contact Name*
Email*
Business Name*
Phone*
Address*
Address Line 2
City*
State*
Zip Code*
Fax*
Current Insurance Company
Company Name*

(not agency)
Date*
MM slash DD slash YYYY
Current Insurance Coverages
Current Coverages*
- Bond
- Commercial Auto
- Commercial Liability
- Commercial Property
- Commercial Umbrella
- Directors & Officers Liability
- Professional Liability
- Workers' Compensation
- Other
Check All That Apply
Other Coverages*
Business Info
# 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 Info
Address*
Occupancy Status*
Year Built*
% Occupied*
Sprinklers*
Construction Type*
# of Stories*
# of Basements*
Sq. Footage*
Burglar Alarm*
Building Value*
Contents*
Other Property*
(specify)
Insurance Info
Other*
Annual Gross Sales: (before taxes)*
# of Employees*
Annualized Payroll*
Cost of Any Subcontracted Work*
Limits Requested*
Describe any claims from the past 5 years*
Additional Comments
Disclaimer Notice*
- I Understand
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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