Create Your Commercial Insurance Request for Quote
Full Name:
Address:
City:
State:
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Phone:
Email (required ):
How many total employees currently work for your company?
What is the breakdown of these individuals?
Select
Full or Part-time Employees:
Sub-contractors/Consultants:
What kinds of business insurance are you interested in purchasing?
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):
What is your business entity (legal entity)?
Select
Corporation
S Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
Sole Proprietorship
Limited Partnership
Professional Corporation
Nonprofit Corporation
How many years has your company been in existence?
Select
Less than 1 year
1 year
2 years
3 years
4 years
5+ years
What is the approximate annual revenue of your business?
Select
Under $100,000
$100,000-$500,000
$500,000-$1,000,000
$1,000,000-$10,000,000
$10,000,000+
How many years of experience does the senior executive of your company
have in your industry?
Select
Less than 1 year
1 year
2 years
3 years
4 years
5+ years
Is this coverage needed for a one-time or seasonal event?
Select
Yes
No
Not Sure
When would you like your plan to take effect?
Select
ASAP
Within one month
In one to two months
More than two months
When my current policy expires
How would you best describe your company’s industry?
Select
SERVICES - Select below
- AccountingAccountants/Bookkeepers
- Advertising Agencies
- Architects/Engineers
- Beauty Shop/Barber Shop
- Consultants
- Doctors/Dentists/Medical Offices
- General Offices
- Law Offices
- Insurance Agents/Brokers
- Manufacturers Representatives
- Publishing Offices
- Real Estate Agents
- Travel Agents
- Veterinarians
- General Repair
- Dry Cleaners
- Photographic Studios
- Printing (Commercial)
- Printing (Instant Print & Duplic.)
- Other Service-based Industry
MANUFACTURING - Select below
- Computer Equipment Mfg.
- Electronics Mfg.
- Food Products Mfg.
- Metal Mfg.
- Metal Working Job Shops
- Office Machines Mfg.
- Plastics Mfg.
- Tool and Die Patterns and Mold Mfg.
- Other Manufacturing-based Industry
CONTRACTORS - Select below
- Janitorial Services
- HVAC
- Cabinet Building & Installation
- Cable Installation
- Carpentry
- Flooring Installation
- Commercial Fence Contractor
- Drywall Installation Contractors
- Electrical Wiring Contractors
- Glass/Glazing Work Contractor
- Landscaping
- Masonry Contractor
- Painting/Wallpapering
- Plumbing Contractor
- Telephone Equipment Installation
- Other Contracting-based Industry
RETAIL/WHOLESALE - Select below
- Appliance Stores
- Automobile Parts
- Bath and Beauty Supplies
- Books/Magazines Retail
- Communications Equipment
- Computer/Office Equipment
- Drug Stores
- Electrical Supplies
- Florists/Garden Shops
- Gift/Souvenir Shops
- Glass Retailer
- Greeting Cards
- Food Stores
- Hardware Stores
- Hobby Shops & Model Stores
- Ice Cream Parlors
- Optical Goods
- Painting/Wallpaper Retailer
- Pet Shops & Pet Supplies
- Picture Frames
- Restaurants
- Shoes
- Sporting Goods
- Toys
- Trophies
- Video Tape Stores
- Other Retail/Wholesale Industry
What is the five digit ZIP code for your office location?
If you currently have business insurance, please indicate the following:
Current provider:
Expiration Date:
Annual Premium Range:
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.