business quotation form

►To supply you with an accurate quote, please complete the following form.

►Information submitted will be confidential and for quote purposes only.

►Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

  

 

 

Name:

 

Email Address: 

 

Phone Number:

 

How would you wish to be contacted about your quote?:

Phone:         Email:

 

If you would prefer to be contacted by phone, please let us know the best time to call:

 

Address:

 

City:

 

State:

 

Zip Code:

 

 

 

Name of Business:

 

Type of Business:

 

Kind of Business:

 

Year Established:

 

Do You Currently have General Liability Insurance?:

Yes:          No:

 

If yes, when does the current policy expire?:

 

If yes, who are you currently insured with?:

 

How many owners are there?:

 

How many full-time employees?:

 

How many part-time employees?:

 

Gross Estimated Sales:

$

 

Estimated Payroll:

$

 

Have you had any claims in the past 3 years:

Yes:          No:

 

I you have any claims in the past 3 years, please describe them below:

 

 

 

 

 

The Following Questions are for Contractors Only:

What percent of your work is residential?:

%

 

What percent of your work is commercial?:

%

 

Do you sub-out work?:

Yes:          No:

 

If yes, what percent?:

%

 

 

 

 

 

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DISCLAIMER                        PRIVACY STATEMENT

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