Business Quote Company NameContact Name First Last Email PhoneEntityIndividualLLCCorporationNumber of Years in Business Number of EmployeesFull timePart timeCurrent carrierExpiration date MM slash DD slash YYYY How long has your business currently been insured?Any claims in the last 3 years? Yes No ExplainDesired Coverage General Liability Property Inland Marine Auto Workers Comp General LiabilityIndustrySub-Contractor costsEstimated annual salesUmbrella Coverage limitsNot Applicable$1 Million$2 Million$3 Million$4 Million+$5 MillionAnnual PayrollPropertyPhysical Building Coverage LimitBusiness Personal Property AmountBusiness Income LimitDeductible Amount$500$1000Year BuiltSquare FootageNumber of StoriesConstructionFrameJoisted MasonryNon-CombustibleInland MarineScheduled EquipmentUn-scheduled EquipmentLeased/Rented EquipmentInstallation FloaterAuto# of Vehicles# of DriversCoverage info Liability Comprehensive Deductibles Collision Deductibles Towing Rental Liability Limit$500,000$1,000,000Comprehensive Deductibles$500$1000Collision Deductibles$500$1000Towing$50$75$100Rental$30 / 30 days$45 / 45 daysWorkers CompIndustryHow many payroll groups does your business have?Payroll 1Payroll 2Payroll 3Payroll 4Payroll 1NameAnnual PayrollPayroll 2NameAnnual PayrollPayroll 3NameAnnual PayrollPayroll 4NameAnnual PayrollCaptchaCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
