Business Commercial Quote Effective Date of Coverage* MM slash DD slash YYYY Company Name* Entity Type* Sole Propiertorship/Partnership LLC/LLP Incorporation Date Business Established*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920FEIN* Business Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact* First Last Phone*Email* ExposuresAnnual Gross Revenue ($)*Officers/Executives* Yes No Additional Employees* Yes No # of Full Time Employees*Please enter a number from 0 to 1000.# of Part Time Employees*Please enter a number from 0 to 1000.Total Estimated Payroll, Excluding Officers ($)*Property InformationProperty Occupancy* Owned Leased Square Footage Your Company Occupies*Total Building Square FootagePlease enter a number from 1 to 100000.Year Built Construction Type Frame Joint Marsonry Steel Other Roof Material Do other companies share building? Yes No Building Security* Yes, local alarm only Yes, central alarm monitoring system None Fire Sprinkler System* Yes No Distance to Nearest Fire Hydrant (feet) Distance to Nearest Fire Station (miles) OperationsDescription of Business Operations/Products/Services*Tell us about your company.Estimated Value of Business Property ($)Equipment, computers, furniture, etc.Estimated Value of Capital Improvements ($) Office build out expenses, permanent fixtures installed, interior renovations, etc.InsuranceCurrently Insured* Yes No Name of Current Carrier* Policy Expiration Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Number of Claims in Last Five (5) Years* 0 1 2 3 Has policy ever been cancelled or non-Renewed In last five years?* Yes No Type(s) of Insurance Coverage Needed:* General Liability Coverage Commercial Auto Coverage Building Coverage Business Property Umbrella/Excess Liability Coverage E&O/Professional Liability Check all that apply.Additional InterestsWill you need certificates of insurance provided to others?* Yes No Landlord, mortgagee, or vendors that require to be a certificate holder.Additional Notes/ComentsPlease provide any additional details that may help us in providing you an accurate proposal.
