WEB REQUEST – Business Quote General InformationContact Name*Email* Business NameAddressCityStateZipCountyBusiness PhoneFaxCurrent Insurance Company (not agency)(not agency) Company NamePolicy Expiration DateCurrent Insurance CoveragesCurrent Coverages Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Professional Liability Workers' Compensation Other Please SpecifyBusiness Information# of Full-Time Employees# of Part-Time EmployeesHow long in Business? (yrs)How many locations?Please give a brief description of your business and clienteleProperty/Premises InformationAddressOccupancy StatusOwnerTenantYear Built% OccupiedSprinklersYesNoConstruction TypeFrameBrick VeneerStuccoMetalConcreteStories# BasementsSq. FootageBurglar AlarmYesNoBuilding ValueContentsOther Property (specify)Insurance InformationOtherAnnual Gross Sales: (before taxes)Number of EmployeesAnnualized PayrollCost of any Subcontracted WorkLimits Requested$300,000$500,000$1,000,000$2,000,000Describe any claims you've had in the past 5 yearsAdditional CommentsDisclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.