|
Professional
Liability and/or General Liability Insurance Quote Request |
|
ABOUT THE OWNER / PRINCIPAL |
|
Company Name:
|
|
|
First Name:
|
|
|
Last Name: |
|
|
Address: |
|
|
City: |
|
|
State: |
|
|
Phone: |
|
| Zip Code: |
|
|
E-mail: |
|
|
Confirm E-mail: |
|
|
ABOUT THE BUSINESS |
| |
|
|
Location: |
|
| |
|
| Business Structure |
|
| |
|
| Choose the types that
represent your business ( you may choose more than one): |
|
| |
|
| Description of Business: |
|
|
Year Started: |
We welcome New Buisinesses. |
|
|
Years experience in industry: |
|
|
| Tax ID # |
|
| |
|
|
PROFESSIONAL LIABILITY
SECTION - OPTIONAL |
|
Professional Liability Limits: |
$
|
| |
|
| Full Time Employees: |
(not owners)
|
|
Part-Time: |
|
|
Number of Partners/Execs: |
|
| |
What types of
clients do you service: |
| |
|
| Do you belong to any
professional associations? |
(if known) |
| |
|
|
Gross Receipts: |
Prior Year
$
(if new business, write NEW and estimate an amount)
|
| |
Current
Year $
|
| |
Estimates for Next
Year $
|
|
Definition of Gross Receipts |
New businesses may estimate their gross receipts,
but we need this information to obtain a quote for most industries.
|
| Annual
Payroll: |
$
(if none, write "none") |
| |
|
| |
|
| Claims: |
|
| |
|
|
Do your customers sign a contract or
written agreement |
 |
| |
|
| Does a single
client represent 50% or more of your business? |
|
| |
|
|
COMMERCIAL GENERAL
LIABILITY SECTION - OPTIONAL |
| |
|
|
General Liability Limits: |
$
|
| |
|
|
Space Occupied (sq feet): |
|
| |
|
|
Year Building Built: |
(estimate is
acceptable) |
| |
|
|
|
|
| |
|
|
PROPERTY INSURANCE -
OPTIONAL |
| |
|
|
Building Security System? |
|
| |
|
| Business personal property
and equipment? |
$
(tools furniture, computers, etc) |
| |
|
| Signs: |
$
(this may include attached or detached signs from
your building) |
| |
|
Tenant Improvements
(Renters) |
$
Do you need coverage for the building itself?
Enter the amount
of coverage here. |
| |
|
Building Insurance
(Building Owners) |
$
Do you need coverage for the building itself? Enter the amount
of coverage here. |
| |
|
| Check other coverages that
you would like: |
Glass
Coverage (Windows)
Business
Income/Extra Expense
ID
Theft
Non-Owner/Hired
Autos
Fences
/ Gates
Mobile
Equipment |
| |
|
| *** |
Do you currently
have insurance (if yes, with which carrier)?
|
| |
|
| |
Current Premium:
(this helps us compare rates)
|
| |
|
| |
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. |
| |
|
| |
|
| |
|
|
|
|
|
| |
|
|