SMALL BUSINESS INSURANCE QUOTATION FORM
To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used 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.

PERSONAL INFORMATION
Business Name:
Contact Name:  First:      
Last:
Business E-mail address: 
Business Phone numbers:  Daytime:
Fax:
Type of Business: 
Number of Years in Business: 
Current Insurance Company: 
Date Coverage Desired: 
Address: 
City: 
State: 
Zip code: 
Briefly describe all losses in last 3 years:

 
PROPERTY
Swimming pool? 
Yes No
Premises Address: 
Building Limit: 
Business Contents Limit: 
Business Income: 
Other: 
Building Construction:  Frame:
Joisted Masonry:
Fire Resistive:
Sprinklered:
Year Building was built: 
If built over 30 years ago, provide when last updated: Roof:
Wiring:
Plumbing:
Heating:
Number of Stories: 
Square feet of building: 
Square feet of space you occupy: 
Type of Occupancy: 
Other Occupancies in Bldg: 
Inside/Outside City Limits:  Inside: Outside:

 
GENERAL LIABILITY

Liability Limits Desired: 
Gross Annual Receipts: 
Annual Payroll: 
 
BUSINESS AUTOMOBILE #1
Year: 
Make: 
Model: 
Serial #: 
Cost (new): 
Where is vehicle garaged:  City: State:
Limit of Liability Desired: 
Comprehensive Deductible: 
Collision Deductable: 
Drivers Name: 
Date of Birth: 
Drivers License #:
Describe any Accidents or Violations in the last 3 years:

 
BUSINESS AUTOMOBILE #2
Year: 
Make: 
Model: 
Serial #: 
Cost (new): 
Where is vehicle garaged:  City: State:
Limit of Liability Desired: 
Comprehensive Deductible: 
Collision Deductable: 
Drivers Name: 
Date of Birth: 
Drivers License #:
Describe any Accidents or Violations in the last 3 years:

 
WORKERS COMPENSATION

Classification if known, or type of work employee does

Number of employees for each classification
Annual Payroll
COMMERCIAL UMBRELLA
Limit Desired: 
MISCELLANEOUS COVERAGES
Type of Coverage 1: 
Limit Desired 1: 
Type of Coverage 2: 
Limit Desired 2: 
Type of Coverage 3: 
Limit Desired 3: