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Business Insurance Quote
BUSINESS INSURANCE QUOTE
Please complete all blanks to ensure that we create the best possible quote for you. If you have any questions, you may reach us during business hours at 877.309.9515 or 815.732.6101. REQUEST FOR A QUOTE DOES NOT BIND COVERAGE!
SECTION 1 CONTACT DATA
Date
*
Name
*
Last, First, Middle
Business Name
*
Last, First, Middle
Business Property Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Email
*
Phone
*
Smoker
Yes
No
SS# or Tax ID#
*
Driver's License #
*
DOB
*
mm/dd/yyyy
Do you have any other Business Locations? Name of Business(es) and Addresses
*
Contact Person
Phone #
FAX #
Email
Website
Effective Date Requested
Description of Business / Services provided (if attorney's office, please list areas of practice)
SECTION 2 - COVERAGES
Current Insurance Company
Expiration Date
Current Policy Being Canceled?
*
Yes
No
Why?
BUILDING CONSTRUCTION
*
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Fire Resistive
(Must have in order to provide a cost estimate)
Year Built
Construction Quality
Fair
Good
Excellent
Claims past 5 years?
Yes
No
In City Limits
Yes
No
Stories
One
One & a half
Two
Bi-Level
Tri-Level
Other
Construction
Site Built
Modular
UPDATES - If building is over 15 yrs old indicate year renovation / replacement of ELECTRIC?
ROOFING?
HEATING?
PLUMBING?
HEATING / AC
Is the Building up to Code?
Yes
No
Sprinkler System
Yes
No
If "Yes" is it Wet (water) or Dry (chemical)
Is distance to responding fire station less than 5 miles?
Yes
No
Is Building located within 1000 feet of a fire hydrant?
Yes
No
Fire Alarm
Local
Central Station
None
Burglar Alarm
Local
Central Station
None
SQ FT Occupied by Business
If Building is owned, Building Coverage Amount Requested
ADDITIONAL INSUREDS
*
(By Contract, Agreement or Permit. Provide Names and Addresses)
SECTION 3 - BUSINESS LIABILITY
Select Limits
$1,000,000 - 2,000,000
$2,000,000 - 4,000,000
SECTION 4 - BUSINESS AUTO
Are any autos titled, owned or leased by the business or corporation
Yes
No
Name of Licensed Driver
DOB
Driver's License #
VEHICLE #1 Make / Model
Year
VIN #
COVERAGES DESIRED: Compensation $
Collision $
Liability $
Towing
Yes
No
Full Glass
Yes
No
Additional Interests / Loss Payee
(Provide Name, Address and Lease #)
VEHICLE #2 Make / Model
Year
VIN #
COVERAGES DESIRED: Compensation $
Collision $
Liability $
Towing
Yes
No
Full Glass
Yes
No
ADDITIONAL INTERESTS / LOSS PAYEE
(Please provide Name, Address and Lease #)
SECTION 5 - OPTIONAL COVERAGES AVAILABLE
Business Liability Limit
$1,000,000 - 2,000,000
$2,000,000 - 4,000,000
Scheduled Equipment Total Approximate Value $
Valuable Papers
$25,000
$50,000
$100,000
Employee Dishonesty
$10,000
$15,000
$25,000
Accounts Receivable
$25,000
$50,000
$100,000
Umbrella Coverage
$1,000,000
$2,000,000
Other
If Other, $ Amount
Worker's Compensation - # of Full-time Employees
# of Part-time Employee
Estimated Annual Payroll $
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We’d love to hear from you. Please call us or email us! We’ll get right back to you.
