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About Us
Health
Employee Benefits
Medicare
Dental and Vision
Business
Home
Auto
Pet
Blog
Contact Us
Request a Consultation
Find An Agent
Commercial Business Quote
Adrian
2017-01-31T13:51:34-06:00
Downloadable Form
Commercial Quote Form
Commercial Quote Worksheet
Step
1
of
7
14%
Insured Information Part 1
Effective Date
*
MM slash DD slash YYYY
Named Insured (Include DBA)
*
Entity
*
Sole Proprietor
Partnership
Corporation
LLC
Contact Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
*
Business Information Part 2
Year Business Established
*
Total Years Experience
*
Email
*
Website
Description of Operations
*
Location Information
You may provide up to five locations
Location 1
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Owner Or Tenant
*
Owner
Tenant
Add 2nd location?
*
No
Yes
Location 2
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Owner Or Tenant Location 2
*
Owner
Tenant
Add 3rd location?
*
No
Yes
Location 3
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Owner Or Tenant Location 3
*
Owner
Tenant
Add 4th location?
*
No
Yes
Location 4
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Owner Or Tenant Location 4
*
Owner
Tenant
Add 5th location?
*
No
Yes
Location 5
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Owner Or Tenant Location 5
*
Owner
Tenant
Location 1 Information Cont.
Construction Type
*
Frame
Joisted Masonry
Masonry Non-Comb.
Other Non-Comb.
Year Built
*
Number of Stories
*
Total Square Feet (Building)
*
Square Feet Occupied (by insured)
*
Sprinklered?
*
No
Yes
Other Occupants in Building?
*
No
Yes
Alarm System
*
No
Yes
Building Updates
Please provide the year that each was updated.
Heating
*
Plumbing
*
Electrical
*
Roof
*
Property Information
Building Coverage
*
Limit
Deductible
Business Personal Property
*
Limit
Deductible
Property of Others
*
Limit
Deductible
Inland Marine
*
Limit
Deductible
Liability Information
Limit
*
Estimated Annual Gross Sales
*
Estimated Annual Gross Payroll
*
Umbrella
Limit
Estimated Annual Payroll
Hired and Non-Owned Auto Coverage
*
No
Yes
Location 2 Information Cont.
Construction Type
*
Frame
Joisted Masonry
Masonry Non-Comb.
Other Non-Comb.
Year Built
*
Number Of Stories
*
Total Square Feet (building)
*
Square feet Occupied (by insured)
*
Sprinklered?
*
No
Yes
Other Occupants in Building
*
No
Yes
Alarm System
*
No
Yes
Building Updates
Please provide the year that each was updated.
Heating
*
Plumbing
*
Electrical
*
Roof
*
Property Information
Building Coverage
*
Limit
Deductible
Business Personal Property
*
Limit
Deductible
Property Of Others
*
Limit
Deductible
Inland Marine
*
Limit
Deductible
Liability Information
General Liability
Limit
*
Estimated Annual Gross Sales
*
Estimated Annual Gross Payroll
*
Umbrella
Limit
Estimated Annual Gross Payroll
Hired and Non-Owned Auto Coverage
*
No
Yes
Location 3 Information Cont.
Construction Type
*
Frame
Joisted Masonry
Masonry Non-Comb.
Other Non-Comb.
Year Built
*
Number Of Stories
*
Total Square Feet (building)
*
Square feet Occupied (by insured)
*
Sprinklered?
*
No
Yes
Other Occupants in Building
*
No
Yes
Alarm System
*
No
Yes
Building Updates
Please provide the year that each was updated.
Heating
*
Plumbing
*
Electrical
*
Roof
*
Property Information
Building
*
Limit
Deductible
Business Personal Property
*
Limit
Deductible
Property of Others
*
Limit
Deductible
Inland Marine
*
Limit
Deductible
Libility Information
General Liability
Limit
*
Estimated Annual Gross Sales
*
Estimated Annual Gross Payroll
*
Umbrella
Limit
Estimated Annual Gross Payroll
Hired and Non-Owned Auto Coverage
*
No
Yes
Location 4 Information Cont.
Construction Type
*
Frame
Joisted Masonry
Masonry Non-Comb.
Other Non-Comb.
Year Built
*
Number Of Stories
*
Total Square Feet (building)
*
Square feet Occupied (by insured)
*
Sprinklered?
*
No
Yes
Other Occupants in Building
*
No
Yes
Alarm System
*
No
Yes
Building Updates
Please provide the year that each was updated.
Heating
*
Plumbing
*
Electrical
*
Roof
*
Property Information
Building
*
Limit
Deductible
Business Personal Property
*
Limit
Deductible
Property of Others
*
Limit
Deductible
Inland Marine
*
Limit
Deductible
Liability Information
General Liability
Limit
*
Estimated Annual Gross Sales
*
Estimated Annual Gross Payroll
*
Umbrella
Limit
Estimated Annual Gross Payroll
Hired and Non-Owned Auto Coverage
*
No
Yes
Location 5 Information Cont.
Construction Type
*
Frame
Joisted Masonry
Masonry Non-Comb.
Other Non-Comb.
Year Built
*
Number Of Stories
*
Total Square Feet (building)
*
Square feet Occupied (by insured)
*
Sprinklered?
*
No
Yes
Other Occupants in Building
*
No
Yes
Alarm System
*
No
Yes
Building Updates
Please provide the year that each was updated.
Heating
*
Plumbing
*
Electrical
*
Roof
*
Property Information
Building
*
Limit
Deductible
Business Personal Property
*
Limit
Deductible
Property of Others
*
Limit
Deductible
Inland Marine
*
Limit
Deductible
Liability Information
General Liability
Limit
*
Estimated Annual Gross Sales
*
Estimated Annual Gross Payroll
*
Umbrella
Limit
Estimated Annual Gross Payroll
Hired and Non-Owned Auto Coverage
*
No
Yes
Package and Umbrella Prior Insurance/Claims History Information
Prior Company
*
Prior Carrier Premium
*
Number of Years w/Prior Carrier
*
Has there been any Claims in the last 4 years?
*
No
Yes
Claims History
*
Data of loss, cause of loss, total amount paid, is the employee involved still employed?
Additional Information
Please enter any additional information here that will help us understand this risk better
Is a Worker's Compensation Quote also desired?
*
No
Yes
Federal Tax ID
Experience Mod
(Applicable for annual premiums over $5,000 only)
Limits
*
$100k/$500k/$100k
$500/$500/$500
$1M/$1M/$1M
Employee Class Code/Duties
You may provide up to five Employee Class Code/Duties
Employee Type
*
Employee Duties
Class Code
# of Employees
Estimated Annual Payroll
State
Owner and Officer Information
You may provide up to five Owners or Officers
Owners/Officers
*
Name
Title
Class
Payroll
Exclude (Y/N)
Workers Comp. Claims Information
Has there been any Workers Comp. claims in the last 4 years?
*
No
Yes
Workers Comp. Claims History
*
Date of loss, cause of loss, total amount paid, is the employee involved still employed?
Additional Information
Prior Carrier
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