Commercial Package Policy Quote Request

Binding Agreement

(Required) I understand that any policy changes and quote requests are effective only when I have received a written confirmation.*

I agree

Your Contact Information

First Name:*

Last Name:*

Title:

Email Address:*

Phone Number:*

How would you like us to follow up with you?*

Email Phone

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Information About Your Business

Business Name:*

Type of Business Entity:*

FEIN:

Please describe your business:*

Number of Full Time Employees:*

Number of Part Time Employees:*

Annual Payroll:*

Annual Gross Receipts:*

Number of Locations:*

How long have you been in business?*

Is there any information about your business you would like to add?

Information About Your Current Insurance

Do you need Commercial Property Insurance?*

Yes No

Do you currently have Commercial General Liability Insurance?*

Yes No

When does your current policy expire?*

Who is the insurance company?*

What is the approximate annual premium?*

Please descibe any claims in the last three years. Please include dates, amounts and descriptions.

Information About Your Business Location

Do you own or lease your premises?*

Lease Own

Building Year of Construction:

Type of Construction:*

Roof construction material?*

Total square feet of building:*

How many square feet does your business occupy?*

Number of Floors:*

How many floors does your business occupy?*

Does the building have elevators?*

Yes No

Does the building have a central fire alarm system?*

Yes No

What % of the building is sprinklered?*

Is there a security system for your business premises?*

Yes No

Does the building have swimming pools?*

Yes No

Does the building have balconies? If so, are grills allowed on the balconies?*

Yes No

If your building is over 25 years old. Please list any updates to:
Roof
HVAC
Plumbing
Electrical

Other Coverage You May Need

Any other comments or information?

*Required fields:

This submission is a request. Insurance coverage changes and new coverages are not effective until we confirm that for you.

We will do our best to furnish a quote based on the information you provide. The more complete your information, the more accurate your quote will be.

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