Create Your Commercial Insurance Request for Quote
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| 1) |
Full Name: |
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| 2) |
Address: |
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| 3) |
City: |
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| 4) |
State: |
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| 5) |
Zip: |
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| 6) |
Phone: |
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| 7) |
Email (required): |
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| 8) |
How many total employees currently work for your company? |
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| 9) |
What is the breakdown of these individuals? |
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Full or part-time Employees:
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Sub-contractors/Consultants:
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| 10) |
What kinds of business insurance are you interested in purchasing? |
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General Liability
Business Owner's Policy (BOP)
Property
Workers' Compensation
Professional Liability / Errors & Omissions (E&O)
Directors & Officers (D&O)
Business Automobile
Marine
Umbrella (Supplemental Liability)
Business Interruption
Key Person Life
Business Travel
Other (please specify):
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| 11) |
What is your business entity (legal entity)? |
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| 12) |
How many years has your company been in existence? |
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| 13) |
What is the approximate annual revenue of your business? |
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Under $100,000
$100,000-$500,000
$500,000-$1,000,000
$1,000,000-$10,000,000
$10,000,000+ |
| 14) |
How many years of experience does the senior executive of your company
have in your industry? |
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| 15) |
Is this coverage needed for a one-time or seasonal event? |
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Yes
No
Not Sure |
| 16) |
When would you like your plan to take effect? |
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ASAP
Within one month
In one to two months
More than two months
When my current policy expires |
| 17) |
How would you best describe your company’s industry? |
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| 18) |
What is the five digit ZIP code for your office location? |
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(We only serve U.S. businesses at this time.) |
| 19) |
What is your e-mail address? |
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| 20) |
If you currently have business insurance, please indicate the following: |
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| 21) |
Please describe any additional requirements or specifics about your
insurance needs (e.g. your current situation and how much coverage you want).
The more information you can provide here, the more accurately out vendors
can be in providing quotes. |
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Note: There is a 1,000 character limit for this answer. |
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I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. |
I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)
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