Commercial Property 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

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Yes No

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 Business Location

Do you own or lease your premises?*

Own Lease

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

Information About Your Current Insurance

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.

Other Coverage You May Need

Any other comments or information?

File Upload

If you have any documents to upload and attach to this form. Please upload them here: (Optional):

Click here to attach a file to this form

*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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