Commercial Insurance Quote

Today's Date:

Your Name:

Your Title:

Company Name:

Premisis Address:

City: State: Zip:

Phone/Extension:

Fax:

Years in Business:

Email (Required):

Description of Operations:

Premisis Address:

Do you currently have insurance?
Select One YES No

If yes, who is your current insurance company:

Policy expiration date :

If No, how long has it been since you have had insurance?

Annual Sales:

Payroll:

Business Income:

Other Insurance company Used in Past 3 Years:

Policy:

Have you had any loses in the past 3 years ?
Select One YES No

Amount paid for each loss:

Description of losses or loss runs:

Coverage Amounts Desired ?
Select One $500,000 $750,000 1 Million 2 Million

Building 1

Building Value: $

Contents Value: $

Total Building Area:

Year Built:

Construction Type ?
Select One Wood Frame Steel Reinforced Mill Concrete Block Concrete Tilt Up Concrete Block

Sprinklers ?
Select One YES No

Electrical Type:

Amps:

Electrical Renovation Year:

Plumbing Renovation ?
Select One None Partial Complete

Plumbing Renovation Year:

Heating Type:

Heating Renovation Year:

Roofing Renovation ?
Select One Partial Complete

Roof Age (years):

Central Alarm ?
Select One YES No

To the right:  Distance:

To the left:    Distance:

To the rear:   Distance:

Your E-mail Address:

Confirm e-mail address:

I acknowledge that all the information on this form is true and correct.(YES or NO)

Comments: