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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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| Prior Claims: |
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| Describe your business here. If you have any special requests, please place them here. |
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| Do you have
one of the following? |
We ask this question because some,
not all, small business policies policies require you to have
insurance at your home if you do not have an office. |
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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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Do you currently
have one of the following? |
We are this question because we have different
policy options and one of them requires that you have one of the
options above. |
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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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