COMMERCIAL INSURANCE
QUOTATION INFORMATION SHEET

Please fill out the following information sheet as completely as possible, so we can provide you with a free and competitive quote for your commercial insurance package.

Business Information

Name/DBA:

  

Telephone Number:

  

Fax Number:

  

Mailing Address:

  

* E-Mail Address:

  

Business Address #1:

  
Own  Lease

Business Address #2:

  
Own  Lease

Business Address #3:

  
Own  Lease 

Contact Person:

  

Best Time to Contact:

  

 

Description of Business

Business Structure:

  

Length of Time in Business

Years: Months:

Type of Business

(Please describe completely all operations):

 

Type of Insurance Coverage(s) Needed

Check each of the following types of insurance that you need:

Property
Commercial General Liability
Umbrella
Glass & Sign
Business Auto
Boiler & Machinery
Accounts Receivable & Valuable Papers
Garage Keepers
Miscellaneous Crime
Crime
Liqueur Liability
Truckers
Transportation
Cargo
Workers Compensation
Special Event
Group Health
Other (describe):

Preliminary Quotation Information

Gross Annual Sales:

  

Number of Employees:

  

Gross Annual Payroll:

  

Square Footage:

  

Prior Insurance Company:

  

Annual Premium:

  

Describe any claim(s) made in past three years:

  

Nature of the claim(s):

  

Explain what has been done to permanently remedy the problem:

  

Date to claim:

  

Amount of loss:

  

Limits of Liability Desired

Please indicate the limits of liability desired for the following. If you are unsure, Please check here and leave this section blank.

Section Limits Alternate Limits Requested
General Liability: 1,000,000
Product & Completed Operations: 1,000,000
Personal & Advertising Injury: 1,000,000
Each Occurrence: 1,000,000
Fire Damage (any one fire): 100,000
Medical Expense (any one Person): 10,000
Other:  

Description and Value of property

Please indicate below the description and value of property to be insured by location. If you are unsure, please check here and leave this section blank.

LOCATION

SUBJECT OF INSURANCE

VALUE
Location #1:      
Location #2:      
Location #3:      
Location #4:      
Location #5:      

 

Building Information
Location # Type of Construction # of Stories Year Build Value Square Footage A* F*

S*
1          
2          
3          
4          
5          
*On building safety features (A, F, or S)
A = Central Station Alarm F = Fire Extinguisher S = Roof Sprinklers