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Professional
Liability and/or General Liability Insurance Quote Request |
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ABOUT THE OWNER / PRINCIPAL |
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Company 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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ABOUT THE BUSINESS |
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Location: |
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| Choose the types that represent your business: |
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| Description of Business: |
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Year Started: |
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Years experience in industry: |
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| Tax ID # |
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PROFESSIONAL LIABILITY SECTION - OPTIONAL |
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Professional Liability Limits: |
$
($250,000 will be quoted if nothing is entered) |
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| Full Time Employees: |
(not owners)
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Part-Time: |
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Number of Partners/Execs: |
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What
types of clients do you service: |
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| Do you belong to
any professional associations? |
(if known) |
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Gross Receipts: |
Prior Year $
(if new business, write NEW and estimate an amount) |
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Current
Year $
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Estimates for Next
Year $
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Definition of
Gross Receipts
New businesses may estimate their gross receipts,
but we need this information to obtain a quote for most industries.
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| Annual Payroll: |
$
(if none, write "none") |
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| Claims: |
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Do your customers sign a
contract or written agreement |
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| Does a single
client represent 50% or more of your business? |
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COMMERCIAL GENERAL LIABILITY SECTION - OPTIONAL |
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General Liability Limits: |
$
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Space Occupied (sq feet): |
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Year Building Built: |
(estimate is
acceptable) |
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Building Security System? |
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PROPERTY INSURANCE -
OPTIONAL |
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| Business personal property
and equipment? |
$
(tools furniture, computers, etc) |
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Building Insurance? |
Do you need coverage for the building itself? If so, please enter the amount
of coverage here. |
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Do you currently have insurance (if
yes, with which carrier)?
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Current Premium:
(this helps us compare rates)
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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, such as extra coverage
for special items. |
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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. |
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Copyright 2012 Stratum
Insurance Agency, LLC |
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General Liability Insurance | Business Owners
Policies | Professional Liability Insurance |
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