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QUOTE REQUEST - Contact Information |
| Organization Name: |
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First Name: |
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Last Name: |
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Address: |
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City: |
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State: |
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Phone: |
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Zip Code: |
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E-mail: |
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Confirm E-mail: |
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| Website: |
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| Gross Receipts: |
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| Number of
Employees: |
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| Year Business
Started: |
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Location: |
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| What types of events do you
plan? If you have any special requests, please place them here. |
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Types of
Insurance Requested: |
General
Liability Insurance (or Business Owners Policy)
Professional
Liability Insurance (E&O)
Workers
Compensation
Cyber
Liability (Technology Risk)
Employment
Practice Liability (EPLI)
Directors
and Officers (D&O)
Crime
Insurance
Surety
Bonds |
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Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here. |
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| Prior Claims: |
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PROPERTY INSURANCE
(added to the general liability quote) -
OPTIONAL |
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| Business personal property
and equipment? |
(office equipment, supplies, furniture) |
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Year Building Built: |
(estimate is
acceptable) |
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Building Insurance? |
(optional and may include tenant improvement coverage, or for the building) |
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Do you currently have insurance (if
yes, with what carrier?
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Current Premium:
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Someone will contact you about your insurance request to go over the
coverage and options usually in the same day.
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE.
Professional Liability Insurance, General
Liability Insurance, Small Office Insurance, Event Planner Insurance
Copyright 2012 Stratum
Insurance Agency, LLC
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