Get a Detailed Quote – Commercial Insurance

Referred To Us By: (Name/Company)*

Personal Information

Business or Company Name*

Contact Name*

First Last

Phone*

Email*

Contact Phone Number:*

Commercial Property Information

Property Address (if different from personal address):

Street Address Address Line 2 City State ZIP Code

Do you have any other business locations?:*

Yes
No

Please list other locations:

Legal Entity:

Insurable Interest:

Effective Date Requested:

MM

DD

YYYY

Description of business/service provided:

# of years in business:

# of years experience in this type of business:

Employer ID # (FEIN):

Total estimated annual reciepts/revenue:

Building Construction

Check all that apply:

Frame (Wood)
Joisted Masonry
Non-Combustible
Masonry- Non-Combustible
Fire Resistive

# of Stories

Squared Ft. occupied by your Business:

Do you own the building?:

Yes
No

(if yes) Building coverage amount requested:

(if you LEASE) Business personal property coverage amount requested:

Building year built:

NOTE: if building is over 20 years old, indicate the year of the renovation/replacement of:

Wiring:

Roofing:

Plumbing:

Heating/AC:

Sprinkler system:

Yes
No

Is it:

Wet (water)
Dry

Fire Alarm - Local Central Station:

Yes
No

Burglar Alarm - Local Central Station:

Yes
No

Does your lease requires ADDITIONAL INSURED for your property Manager and/or the property owner?

Yes
No

Workers Compensation Questionnaire

Total # of Full-Time employees:

Total # of Part-Time employees:

Total estimated annual payroll for all employees:

Prior insurance company:

Policy Number:

Expiration date:

MM

DD

YYYY

Payroll Premium:

Current Year:

1st Prior Year:

Officer's Ownership Info

Ownership MUST be accurate & total up to 100%

President:

DOB

MM

DD

YYYY

Ownership %

Secretary:

DOB*

MM

DD

YYYY

Ownership %

Treasurer:

DOB

MM

DD

YYYY

Ownership %

Other:

DOB

MM

DD

YYYY

Ownership %

Exclude officers?:

Yes
No

Include officers?:

Yes
No

Special Instructions For Our Staff (if any)

Document Upload (if any)

Commercial Insurance Quote

Step Two: Fill Out The Form Below

Personal Information

Commercial Property Information

Building Construction

NOTE: if building is over 20 years old, indicate the year of the renovation/replacement of:

Workers Compensation Questionnaire

Officer's Ownership Info

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