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Commercial Quote

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General Information

Contact Name: *

Age: *

Email: *

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Business Name

Address: *

City: *

State/Province: *

Zip/Postal Code: *

County *

Business Phone: *

Fax: *

Current Insurance Company

(not agency)

Company Name

Policy Expiration Date

Current Insurance Coverages

Current Coverages

Bond

Commercial Auto

Commercial Liability

Commercial Property

Commercial Umbrella

Directors & Officers Liability

Disability

Group Health

Group Life

Professional Liability

Workers' Compensation

OtherOther

Business Information

# of Full-Time Employees

# of Part-Time Employees

How long in Business? (yrs)

How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

Address

Occupancy Status

Owner

Tenant

Year Built

% Occupied

Sprinklers

Yes

No

Construction Type Frame Brick Veneer Stucco Metal Concrete

Stories

# Basements

Sq. Footage

Burglar Alarm

Yes

No

Building Value

Contents

Other Property (specify)

Insurance Information

Other

Annual Gross Sales: (before taxes)

Number of Employees

Annualized Payroll

Cost of any Subcontracted Work

Limits Requested

$300,000

$500,000

$1,000,000

$2,000,000

Describe any claims you've had in the past 5 years

Additional Comments