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Secure Quote Request
Insured Name
*
Business Name
Phone Number
*
Email Address
*
Business Website Address
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
Tax ID Number
Effective Date From
Date Format: MM slash DD slash YYYY
Effective Date To
Date Format: MM slash DD slash YYYY
Desired Renewal / Premium (Enter "Don't Know" If Not Sure)
Current Insurer
Years in Business
Legal Entity (LLC, Corp, Partnership, etc.)
Nature of Business / Description of Operations
What Type of Policy Do You Need?
*
Business Owners
Commercial Auto
Workers' Compensation
Business Owners Policy / All Other Policy Types
Owner's Management Experience in Years
Liability Limits Desired
300K
500K
1M
Total Gross Payroll
Total Sales
Hours of Operation - Open Time
Hours of Operation - Close Time
Building Own or Lease
Own
Lease
Building Value
Year Building Built
Type of Construction
Number of Stories
Square Feet
Burglar Alarm
Yes
No
Fire Alarm
Yes
No
Is your loss ratio (average annual losses/quoted premium) less than 40%?
Yes
No
Number of Full Time Employees
Number of Part Time Employees
Do you use temp workers?
Yes
No
Do you use sub-contractors?
Yes
No
Any outstanding suits or liens against the business and/or any bankruptcies in the last 3 years?
Yes
No
Commercial Auto Policy
Garaging Address of Vehicle (If different from above)
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
How is Vehicle Used
Liability Limits Desired
Gross Vehicle Weight
Physical Dam Deductibles Desired
Radius of Operation
Vehicle Information
Year
Make
Model
Cost New
Press the "+" symbol to add another vehicle.
Driver Information
Full Name
License #
Date of Birth
Press the "+" symbol to add another driver.
Coverages Needed (Check all that apply)
Additional PIP
Medical Payment
Towing/Labor
Comprehensive
Collision
Hired/Non-Owned Auto Rental
Please List All Accidents in Past 3 Years
Press the "+" symbol to add another accident.
Please List All Moving Violations in Past 3 Years
Press the "+" symbol to add another moving violation.
Have you been canceled for non-payment of premium within the last 3 years?
Yes
No
All price indications are pending favorable loss history for prior 3 years and favorable MVRs.
Workers' Compensation Policy
Liability Limits Desired
100/500/100
500/500/500
1M/1M/1M
Class & Payroll
Class Code
# Employees
Payroll ($)
Description
Press the "+" symbol to add another class.
Have you been in operation for at least 3 years?
Yes
No
Do you have prior workers' compensation coverage?
Yes
No
Hours of Operation - Open After 6 PM?
Yes
No
Hours of Operation - Open After 9 PM?
Yes
No
Hours of Operation - Open After Midnight?
Yes
No
Hours of Operation - Open After 2 AM?
Yes
No
Is your loss ratio (average annual losses/quoted premium) less than 40%?
Yes
No
Do employees handle hazardous materials?
Yes
No
Do employees ever work at heights exceeding 15 feet?
Yes
No
Are employees involved in trucking or transportation operations?
Yes
No
Number of Full Time Employees
Number of Part Time Employees
Maximum number of employees working at one time at a location?
Comments & Agreement
Additional Comments or Questions?
By checking this box, I understand that the information provided above (and, possibly, additional information gathered later) is to be used to get non-binding pricing indication. Coverage cannot be bound without additional information, including a signed application.
*
I Agree