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Business Policy- Quote Request


FOR MULTIPLE LOCATIONS -- complete this form for Location One and submit. Then click "Home" and "Business Quote" and select  "Additional Locations-Supplement" to add information about additional locations.More than 5 locations? You may request a special form by request.  Click   Contact Us

How did you hear about us?
Optional
Do You Have Insurance?
Required
Company Name
Required
Business Type
Optional
Fed Employer ID No
Required
Street
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Type of Location
Required
Company Owner
Last Name
Required
First Name
Required
Primary Phone Number
Required
Years in Industry as Owner or GM
Required
E-Mail Address
Required
Does Applicant Own/Operate Other Businesses?
Optional

Current Insurance Provider
Optional
Current Premium
Optional
Effective Date
Optional
/ /
Claims/Property Losses in Past 5 Years (Please Explain)
Optional
Prior Pollution Complaint,Lawsuit, Claim?
Optional
Liability Limit
Required
Umbrella - amount (if needed)
Optional
Policy Deductible
Required
LOCATION NUMBER
Required
Location Address
Required
Hours of Operation
Required
# of Additional Insureds
Optional
Annual Gross Sales
Required
% of Sales from Retail
Optional
% of Sales from Wholesale
Optional
% of Sales from Home Delivery
Optional
% of Sales from Fire Restoration
Optional
Storage - Max. Limits
Optional
Number of Employees
Optional
Business Personal Property Limits
Required
Building Limits
Optional
Type of Solvent
Required
Haz Waste Hauler - Name
Optional
Sign - Attached Outside Sign Value
Optional
Value of Outside Awning (if any)
Optional
Sign- Detached Outside Sign Value
Optional
Age of Building
Required
Age of Boiler
Optional


Hold down the Ctrl Key to make multiple selections.
Age of Cleaning Machine
Optional


Hold down the Ctrl Key to make multiple selections.
Square Footage of Your Occupancy
Required
Construction Type
Required
Number of Stories
Required
Burglar Alarm - Central Monitor
Optional
Fire Alarm - Centrally Monitored
Optional
Sprinkler System
Optional
Roof - Updates or Replacement - Year
Optional
Electrical Updates - Year
Optional
Plumbing Updates - Year
Optional
Type of Business on both sides (if in attached blding)
Optional
Free Standing Location or Attached (eg. strip)
Required
Occupancy Rate
Required
Additional Comments
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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