Insurance Type*
Please select one...
General Liability
GL & Property
Property
Special Needs
Other
Business Name
Contact Name*
Email Address*
Phone Number*
Fax Number
Business Address
City, State, Zip
Fed Tax ID # or SSN
Number of Owners/Execs
Select Number of Owners...
1
2
3
4
5
6
7
8
9
10 or more
Business Entity
Select Business Entity Type...
Individual
Partnership
Corporation
Joint Venture
Subchapter S-Corp
Not For Profit Org
Limited Liability
Corp
Full-Time Employees
Select Number of Full-Time Employees...
Owner(s) Only
1
2
3
4
5
6
7
8
9
10 or more
Part-Time Employees
Select Number of Part-Time Employees...
None
1
2
3
4
5
6
7
8
9
10 or more
Est. Annual Payroll
Est. Annual Receipts
Years In Business
Select Years in Business...
New Business
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15 or more
Years Experience
Select Years Experience...
None
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15 or more
Physical Characteristics:
Home Based?
Building Value ($)
Contents Value ($)
Year Built
Construction Type
Select Construction Type...
Frame
Joisted Masonry
Non-Combustable
Masonry Non-Combustable
Modified Resistive
Fire Resistive/Superior
Total Square Footage
Number of Stories
Select Number of Stories...
1
2
3
4
5
6
7
8
9
10 or more
Ownership
Select Ownership
Rent
Owner/Mortgaged
Owned/Not Mortgaged
Burglar Alarm Type
Select Burglar Alarm Type...
None
Central/Monitored
Burglar
Local Burglar
Fire/Burglar
Combination - Monitored
Fire/Burglar
Combination - Local Only
Other
Fire Alarm Type
Select Fire Alarm Type...
None
Central/Monitored
Fire
Local Fire
Fire/Burglar
Combination - Monitored
Fire/Burglar
Combination - Local Only
Smoke
Other
Fire Sprinkler
Current Policy:
Current Insurance Company
Select Insurance Company...
None
AIG
Chubb
CNA
Fireman's Fund
Hanover
The Hartford
Expiration Date
Expiring Premium ($)
Years Without a Lapse
Select Years Without a Lapse...
1
2
3
4
5
6
7
8
9
10 or more
Claims In The Last 3 Years
Select Number of Claims...
None
1
2
3 or more
Coverage Desired:
Desired Coverage Limits
Select Coverage Limits...
$100,000/$300,000
$300,000/$500,000
$500,000/$1,000,000
$1,000,000/$2,000,000
Umbrella Policy
Request
Desired Deductible
Select Desired Deductible...
$500
$1000
$1500
$2500
$5000
Desired Effective Date*
Description Of Business Operations*
*Required Field
