Business Quote Company Name Contact Name First Last Email PhoneEntityIndividualLLCCorporationNumber of Years in Business Number of EmployeesFull time Part time Current carrier Expiration 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 LiabilityIndustry Sub-Contractor costs Estimated annual sales Umbrella Coverage limitsNot Applicable$1 Million$2 Million$3 Million$4 Million+$5 MillionAnnual Payroll PropertyPhysical Building Coverage Limit Business Personal Property Amount Business Income Limit Deductible Amount$500$1000Year Built Square Footage Number of Stories ConstructionFrameJoisted MasonryNon-CombustibleInland MarineScheduled Equipment Un-scheduled Equipment Leased/Rented Equipment Installation Floater Auto# of Vehicles # of Drivers Coverage 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 CompIndustry How many payroll groups does your business have?Payroll 1Payroll 2Payroll 3Payroll 4Payroll 1Name Annual Payroll Payroll 2Name Annual Payroll Payroll 3Name Annual Payroll Payroll 4Name Annual Payroll CaptchaCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
