Basic Info
Business Name: * Contact E-mail: * Contact Phone: * Commercial Insurance Types:
Brief Description of Business:
Will this replace any existing policies? Contact's First Name: Contact's Last Name: Business Street Address: ------------------------------------------------------------(Not P.O. Box)------------------------ City: State: Zip Code: Legal Entity Status: -Select- Individual/Sole Proprietorship Joint Venture Partnership Corporation Limited Liability Corporation Municipality Trust
Number of Full-Time Employees (including owner): -Select- None 1-2 3-5 6-10 Over 11
Number of Part-Time Employees: -Select- None 1 2-3 4-5 6-10 11-19 Over 20
Number of Years in Business: -Select- 0-2 3-5 6-10 Over 10
Gross Annual Payroll -Select- Less Than $50000 $50000 - $100000 $100000 - $200000 $200000 - $500000 More Than $500000
Annual Gross Revenue -Select- Under $100000 $100000 - $500000 $500000 - $1000000 $1000000 - $10000000 More Than $10000000
Years of Experience Within the Industry -Select- 0 - 3 4 - 10 Over 11
Desired Amount of General Liability Coverage -Select- $500000 $1000000 $1500000 $2000000 More Than $2000000
Please complete this section if you need building insurance too
----------------------------(otherwise skip to the bottom now and press Continue)------------------------ Year Building Built: Total Square Footage of Building: Square Footage Occupied by Business: Physical Building Coverage Limit: $ Business Personal Property Amount: $ Desired Deductible Amount: $ -Select- $500 $1000 $1500 $2000 $2500
Construction Type: Frame Joisted Masonry Masonry Non-Combustible Modified Resistive Fire Resistive Superior
Number of Stories: -Select- 1 - 2 3 - 5 6 - 10 More Than 10
Fire Alarm Type: -Select- None Central/Monitored Local/Audible Other
Burgular Alarm Type: -Select- None Central/Monitored Local/Audible Other
Additional Properties to Insure?
Do not enter anything in this field: