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Business Owners
"20 Question Quote" Form

Please take a moment to fill out the form below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

1. Insured Name:
  Phone Number:
  E-mail:
2. Business Name:
  Business Website:
3. Address:
  City:
  State:     Zip:
4. Tax ID Number:
5. Effective Dates: to
6. Desired/Renewal Premium:   (Don’t Know )
7. Years in Business:
8. Owner’s Management Experience: years
9. Current Insurer:
10. Legal Entity (LLC?  Corp?  Partnership?):
11. Nature of Business/Description of Operations:
12. Total Gross Payroll:
13. Total Sales:
14. Liability Limits Desired:
300K   500K   1M
15. Hours of Operation: From to
16. Building Own or Lease? Own Lease
Values: $
17. Building Questions:
  Year Built:
  Type of Construction:
  Number of Stories:
  Square Feet of the Business:
  Burglar Alarm?: Yes No
  Fire Alarm?: Yes No
18. Is your loss ratio (average annual losses/quoted premium) Yes No
less than 40%?
19. Employees:
  Number of full-time employees?
  Number of part-time employees?
  Do you use temp workers? Yes No
  Do you use sub-contractors? Yes No
20. Any outstanding suits or liens against the business and/or any bankruptcies last 3 years? Yes No
   

REQUIRED. By checking this box, I understand that the Information provided above (and, possibly, additional information) to be used to get non-binding pricing indication.



 
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