Your Company's Full Name:    

Type of Entity:   Individual    Partnership    Corporation    Other

Your Name as Contact:
Your email address:           
Your phone number:           
Your street address:
Your city:                          

Your State:                        

Your zip code:                   
County (not Country):    

How many years has THIS company been in business?

How many years experience has the owner had in this TYPE of business?

Describe your business.  What products or services do you perform?

 

Type(s) of insurance wanted to quote.  Click all that apply:

Commercial Property     Commercial Liability    Inland Marine(tools or Equipment)

Glass      Crime      Other(s)

 

Commercial General Liability

How many owners and/or officers are there?

How many OTHER employees are there?    

What is the estimated annual payroll per year (not including owners/officers)

Describe the liability limits and coverages you want:

 

 

Commercial Property Insurance:

Skip to next section if you don't want Property

Responding Fire Dept:
Miles from Fire Dept:
Is there a fire hydrant within 1,000 feet Y or N?
Describe what type of coverage you are looking for including building & contents limits, deductibles, etc.

 

 

Other Coverages Wanted:

Skip to next section if you don't want any other coverages

 

Describe what other coverages you want

Currently Insured? Yes           No

If yes to currently insured, please answer the following:

Current Insurance Company:                   
Policy Number:                                      
Annual Premium you are paying currently:
Expiration date of current policy:             

Is your current company canceling or non-renewing you?  If so, Why?

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If you chose "Other Search Engine, which one? or if you chose "Other", What?

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