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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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| Business Structure |
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| Choose the types that
represent your business ( you may choose more than one): |
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| Description of Business: |
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Year Started: |
We welcome New Buisinesses. |
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Years experience in industry: |
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| Tax ID # |
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Business Information |
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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 is the highest value
car on which your will work? |
$ |
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| Driving Records: |
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What types of
clients do you service: |
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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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COVERAGE OPTIONS |
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| Liability Limits
Requested: |
$
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| Type of Coverage |
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Space Occupied (sq feet): |
(if you do not have a physical location, please write 0) |
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Year Building Built: |
(estimate acceptable,
if you do not have a physical location, please write 0)) |
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PROPERTY OR EQUIPMENT INSURANCE -
OPTIONAL |
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Building Security System? |
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| Business personal property
and equipment? |
$
(tools furniture, computers, etc) |
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| Signs: |
$
(this may include attached or detached signs from
your building) |
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Tenant Improvements
(Renters) |
$
Do you need coverage for the building itself?
Enter the amount
of coverage here. |
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Building Insurance
(Building Owners) |
$
Do you need coverage for the building itself? Enter the amount
of coverage here. |
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| Check other coverages that
you would like: |
Glass
Coverage (Windows)
Business
Income/Extra Expense
ID
Theft
Non-Owner/Hired
Autos
Fences
/ Gates
Mobile
Equipment |
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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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