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Small Business Quote Request
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Small Business Quote Request
So, you think you got a pretty good deal on your business insurance? Check it out!
This form takes about ten minutes to complete on a slow day.
If we can save you $300, that's $30 per minute, times 60 minutes, or $1,800.00 per hour.
That's a lotta lasagna!!!
Ok, ok, so you don't even like lasagna. How about corned beef and cabbage?
Whatever...just complete and click submit.
Type of Entity
Sole Proprietorship
Partnership
Corporation
Company Name
Last Name
First Name
DBA
Phone Number
Address
Federal ID Number
Policy Effective Date
Current Insurance Carrier
What Do You Do?
General Liability
General Aggregate
Personal Advertising
Product/Completed Ops
Professional Liability
Each Occurrence
Other Coverage
Property
Building
Deductible
Contents
Business Income
Extra Expense
Value of Computers (EDP)
Commercial Umbrella Liability
Coverage Amount
Building: Is This The Only Location?
Location
Number
Square Footage
Building Materials
Age
Security System
Date Improved / Roof
Date Improved / Wire
Date Improved / Pipe
Date Improved / Heat
Neighbors: Right Side & Distance
Neighbors: Left Side & Distance
Neighbors: Rear Side & Distance
Glass Coverage?
Yes
No
Business
Annual Sales
Number Employees
Cash Over Night
Workers Compensation
Coverage
Excluded Officers
Total Payroll
Name
Title
Class Codes
Payroll
Name
Title
Class Codes
Payroll
Name
Title
Class Codes
Payroll
Name
Title
Loss History
Remarks
