Business Insurance Quote Form

Requested Effective Date:      
         
BUSINESS PROFILE INFORMATION:    
1st Named Insured: First:   MI:   Last:
Title/Position:   If Other:      
Complete Business Name:    
Business Mailing Address:    
  City:      State:      Zip:   
Phone:      
Fax:      
Cell:      
Email:      
Business Physical Address:    
  (If Different) City:      State:      Zip:   
Name of Office Manager: First:   MI:   Last:
         
PLEASE TELL US ABOUT YOUR BUSINESS::    
Are all operations located in the United States? YES   NO  
Are your premises equipped with a burglar alarm? YES   NO  
Do any of your locations generate over $20 Million in revenue? YES   NO  
Do any of your locations have over $5 Million in property value? YES   NO  
Do you operate any other type of business in addition to this one? YES   NO  
Help us to understand your business operations by providing a detailed description of what types of work you do. (Please include information about products sold, services, customers, etc.)

      
What were your annual billings or sales last year?  
What are your projected annual billings or sales for this year?  
What is the legal structure of your business?   If Other:  
What is your Federal Employer Identification Number (FEIN)?  
  (If you are a sole proprietor, please provide the owners Social Security Number)      
What year was your business established?  
How many years of industry experience does the owner of the business have?  
How many owners, partners and/or corporate officers does your business have?  
How many full-time employees do you have (not including partners/officers)?  
How many part-time employees do you have?  
How many seasonal employees do you have?  
Do you lease employees to or from another firm? YES   NO  
Please list your annual payroll for the following:    
      Owners, partners and/or corporate officers  
      Full-time employees (not including partners/officers)  
      Part-time employees (not including partners/officers)  
      Seasonal employees (not including partners/officers)  
Do you use subcontractors? YES   NO  
What percentage of your work is performed by subcontractors?   %  
Please describe the type of work your subcontractors perform. (please be specific)

      
Do you require certificates of insurance for all subcontractors? YES   NO  
Do your subcontractors carry General Liability, Automobile Liability, Workers Compensation and Umbrella Liability equal to your policy limits? YES   NO  
Do you supervise all of the subcontractors you use? YES   NO  
      If No, please explain.

      
         
PROPERTY INSURANCE SECTION::    
Your business is located at:   If Other:  
    (If Commercial Property-Owned) What is the construction type?   If Other:  
What percentage of the whole building do you occupy?   %  
Is more than 25% of the building vacant? YES   NO  
How many stories does your building have?  
What year was the building constructed?  
What is the building's distance from the nearest fire hydrant?   Feet  
What is the building's distance from the nearest fire station?   Miles  
Please enter the name of the first responding fire department.  
     
*Please ensure all fields have been completed before clicking Send.