Commercial / Business Insurance Quote  * Required fields

* Street Address:

* City:   * State: AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD M MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY   * Zip:

* Home Phone:           Cell Phone:    Email:

Best Time to Contact You:    AM    PM             

Underwriting Information:

Nature of Business:

Individual      Partnership     Corporation

# of Owners:    Payroll of Owners:   # of Employees:     Payroll of Employees:   

Total Annual Gross:   Business License #:   License Type:

Years of Experience:   Years Operated Under Current Name: 

Used any other business names during the past 5 years?   Yes    No   If Yes:

Open 24 Hours:  Yes   No        Deep Frying: Yes    No

Manufacturing:  Yes   No         Propane Tank Filling:  Yes   No

Please describe the nature of your business and ANY unusual exposures:    

Building & Property Information:

Total Sq Ft of Business Bldg:      Total Sq Ft of your Business Only:  

Square Footage of Customer Area:    Stories:  1   2   Ground Floor Square Footage: 

Construction Type (Brick, Stone, Frame-Masonry, Frame-Stucco, Masonry-Veneer):  

Roof Type:   (Asphalt/Fiberglass Shingles, Concrete, Steel, Tile, Wood Shake)  

Roof Updated:  Yes   No          Year Roof Updated: 

Do you have a storage area more than 1500 Sq. Ft.?   Yes   No

Smoke Detectors: Yes   No      Fire Extinguishers: Yes   No

Deadbolts:  Yes   No       Are there circuit breakers? Yes   No

Is the electrical updated?  Yes   No   Full Update    Partial Update    Year Updated:

Is the HV/AC thermostatically controlled?  Yes   No       Is the HV/AC central?  Yes   No

Is the plumbing updated? Yes   No   Full Update     Partial Update    Year Updated 

Does the building have interior automatic fire sprinklers? Yes   No

Is there a theft alarm?  Yes   No    Is there a fire alarm? Yes    No

Are there any restaurants in your building?   Yes     No   

Are there any restaurants in the building next to your business? Yes    No

Claims Information:

Where there any losses or claims in the last 5 years?  Yes   No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information:

What is the name of the current insurance company?     

How much are you paying now for Current Coverage?  

Liability limit requested?   Select: $100,000 $300,000 $500,000 $1,000,000

Building limit requested?   

Building deductible requested?   Select: $500 $1,000 $2,500

Business personal property (contents) limit requested?  

Contents deductible requested?   $500 $1,000 $2,500

Loss of income amount requested?

Are there any questions, comments, additional coverage, or Service You Require?