General Information:
Name of Business:
Contact Name:
E-mail:
Street Address:
City:
State:
Zip:
County:
Business Phone:
Fax:
Best time to call:
AM
PM
Current Insurance Company (not agency):
Company Name:
Policy Exp. Date:
What type of coverages do you currently have:
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Business Information
# of full-time employees
# of part-time employees
How long in business
yrs
.
How many locations
Annual Sales
$
Please give a brief description of your
business and clientele
Any losses in the past 5 years
Yes
No Date of loss
If yes, please explain
Please select the type of coverages you want:
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Additional Comments:
Please give any additional comments about the coverage you desire:
