Small Business Insurance Quote Form

Full Business Name (D/B/A)

Corporation Name

Owner / Contact Person Name

Phone No.

Business Phone No.

Years in this Location

Years in this Business

Contact Person

Contact Person Phone

Exact Nature of Business

Requested Effective Date

Legal Entity

Street Name

City

State

Zip

County

Click here, if same as above

Street Name

City

State

Zip

County

Requested Building Limit: $ (if customer owns the building)

Construction Type

Square Footage of Business

No. of buildings owned by customer

Year Built

Year Roof Updated

Year Electrical Updated

Year Plumbing Updated

Year Heating Updated

Miles To Fire Department

Annual Gross Sales/Receipts: $

Number of Employees

Annual Payroll: $

Does Building have a sprinkler system?(subject to verification)(Y/N)

Deductible

Current Carrier

Current Premium: $

Optional coverage (list those of interest)

Loss History (list all losses in last 3 yrs, including details, amount paid, and if case is open or closed)

Do you want to upload any document or file ?

(".txt", ".doc", ".docx", ".xls", ".xlsx", ".csv", ".pdf" files only)