Business Owners Insurance Quote

One Simple Form-takes only 2-3 Minutes!

       guaranteed response within 48 business hours!!

Don't want to fill out this form, well then call us now at 561-732-9305 or 1-800-397-8780

 or click here and we will contact you!

Company Name
Your Name
Title
Type of Company	Select One CORP LLC INDIVIDUAL PARTNERSHIP
Mailing Address City, ST Zip	, ,

County
E-mail
Phone
Fax
Company Website
How Did you hear about us?	Referral Yellow Pages Post Card Newspaper Other If referral If referral please provide name we send like to reward anyone who refers us clients
How would you like us to send you the quote?	Select One Phone Fax Email
Why Do you want to leave your current insurance company?

What Does your Business Do?
Federal Employer Identification Number
Years in Business
Current Ins Carrier	2008-Insurance Company Name Policy Number Expiration Date How many years have you been with them?
Hours Of Operation	OpenClosed
Do you sub-contract any work out to others? How Much %?
Years Experience in this type of business
Sales or Receipts Annually)
Do you own any other company?	No Yes If yes please describe Below

General Liability Coverage

Liability Limit None 300,000 500,000 1,000,000 2,000,000 3,000,000 4,000,000

Amount of Employees (Full) (Part-Time)

Payroll without owners

Owner's Payroll

Professional Liability (Y/N) NO YES

If yes, we will either fax you or email you the supplemental application shortly.

Liquor Liability (Y/N) None Y

If yes, we will either fax you or email you the supplemental application shortly.

Any Additional Insureds (Y/N) N Y

If yes please list them and relationship

Square Footage you Occupy

Customer Area (Restaurants Only)

Do you have a deep fat fryer (restaurants and Bakeries only)? N Y

Any General Liability Claims in last 5 years? (Y/N) No Yes

Date of Loss

If Yes Please describe Below

Umbrella Policy NO YES

Umbrella Liability Limit None 1,000,000 2,000,000 3,000,000 4,000,000

Property Coverage  

Is your location address the same as your mailing address? If no please enter address

Building Coverage

Personal Property/Inventory Coverage None 3000 4000 5000 6000 7000 8000 9000 10000 15000 20000 25000 30000 35000 40000 45000 50000 55000 60000 70000 75000 80000 90000 100000 110000 120000 130000 140000 150000 160000 170000 180000 190000 200000 Other

If Other please enter

Glass Coverage None 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 15000

Signs Coverage  None 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 15000

Spoilage Coverage  None 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 15000 25000

Money & Securities None 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 15000 25000

Business Income Coverage None 12 Months Coverage 25% of Sales 50% of Sales

Year Built of Building

Roof Type

Updates on Building (if over 35 years old) "Roof, Electrical, Plumbing"

Roof

Electrical

Plumbing

Type of Construction None Masonry Frame Non-Combustible (Metal Roof Supports) Masonry Non-Combustible (Metal Roof supports)

How many Stories is the Building? 1 2 3-15

Square Footage you Occupy

What Floor are you on? 

Sprinklers (Y/N) No Yes

Central Alarm (Y/N) No Yes

Any Property Claims in last 5 years? (Y/N) No Yes

Date of Loss

If Yes Please describe Below

Deductible None 500 1000 2500

Wind Deductible None 2% 3% 5% 10%

Do you have any other Locations? No Yes

If yes please we need address's and fill out location #2

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

YES

NO

Agent Use Only	Agent Use Only rtm ht cp km rl mw cm

 Comments/Questions

 guaranteed response within 48 business hours!!

Don't want to fill out this form, well then call us now at 561-732-9305 or 1-800-397-8780 or click here and we will contact you!