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Glossary
Property Liability Quote
Commercial Property Insurance Quote
Name of Business:
Contact Name:
Premises Address:
City:
State:
Zip:
Business Phone:
Fax Number:
Contact Email Address:
Years in Business:
Description of Operations or SIC code(s):
Current Insurance Information
Current Insurance Carrier:
Premium: $
Expiration Date:
Annual Sales: $
Payroll: $
Business Income: $
Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years:
Select One
Yes
NO
Amount paid for each loss: $
Description of losses or loss runs:
Coverage's Desired
Liability Limit Desired:
Select One
$500,000
$600,000
$1 million
$2 million
Deductible Desired:
Select One
$None
$1,000
$2,500
$5,000
Or choose other liability limit amount: $
Umbrella Amount Desired:
Select One
None
$1 million
$2 million
$3 million
$4 million
$5 million
Building 1
Building Value: $
Contents Value: $
Total Building Area:
Year Built:
Construction Type:
Select One
Wood Frame
Steel Reinforced
Mill
Concrete Block
Concrete Tilt Up
Sprinklers:
Select One
Yes
NO
Electrical Type:
Amps:
Electrical Renovation Year:
Plumbing Renovation:
Select One
None
Partial
Complete
Plumbing Renovation Year:
Heating Type:
Heating Renovation Year:
Roofing Renovation:
Select One
Partial
Complete
Roof Age (years):
Central Alarm:
Select One
Yes
NO
List Neighboring Businesses:
To the right:
Distance:
To the left:
Distance:
To the rear:
Distance:
Building 2
Building Value: $
Contents Value: $
Total Building Area:
Year Built:
Construction Type:
Select One
Wood Frame
Steel Reinforced
Mill
Concrete Block
Concrete Tilt Up
Sprinklers:
Select One
Yes
NO
Electrical Type:
Amps:
Electrical Renovation Year:
Plumbing Renovation:
Select One
None
Partial
Complete
Plumbing Renovation Year:
Heating Type:
Heating Renovation Year:
Roofing Renovation:
Select One
Partial
Complete
Roof Age (years):
Central Alarm:
Select One
Yes
NO
List Neighboring Businesses:
To the right:
Distance:
To the left:
Distance:
To the rear:
Distance:
Additional Comments
Please give any additional comments or questions
No coverage of any kind is bound or implied by submitting information via this online form
Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.
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