BUSINESS INSURANCE QUOTE FORM
BUSINESS NAME
MAILING ADDRESS
PHONE (###-###-####) LEGAL STATE
CORPORATION INDIVIDUAL PARTNERSHIP
DESCRIPTION OF NORMAL OPERATIONS
POLICY EXPIRATION DATE (mm/dd/yy)
LOSS HISTORY - PLEASE PROVIDE US A COPY OF YOUR CLAIMS HISTORY FOR THE LAST THREE YEARS
GENERAL LIABILITY
CURRENT INSURANCE CARRIER

POLICY LIMITS GENERAL AGGREGATE
EACH OCCURRENCE
PROPERTY
CURRENT INSURANCE CARRIER
LOCATIONS TO BE COVERED
BUILDING LIMIT $
CONTENTS LIMIT $
BUSINESS INCOME $
BUILDING CONSTRUCTION
YEAR BUILT SQUARE FOOTAGE
 
AUTOMOBILE
CURRENT INSURANCE CARRIER

PLEASE PROVIDE A LIST OF DRIVERS

CURRENT POLICY LIMITS $

CURRENT DEDUCTIBLES $
COMPREHENSIVE $
COLLISION $

PLEASE PROVIDE A LIST OF VEHICLES

WORKERS COMPENSATION
CURRENT INSURANCE CARRIER
FEDERAL IDENTIFICATION NUMBER
WHAT IS YOUR CURRENT EXPERIENCE MODIFICATION FACTOR
ARE OWNERS OFFICERS TO BE INCLUDED EXCLUDED
PLEASE PROVIDE A LIST OF VEHICLES
PLEASE PROVIDE THE CLASSIFICATIONS AND PAYROLLS
COMMERCIAL UMBRELLA
CURRENT INSURANCE CARRIER

CURRENT POLICY LIMITS

EQUIPMENT
 
PLEASE PROVIDE A LIST OF THE ITEMS TO BE COVERED ALONG WITH SERIAL NUMBERS AND VALUES