Commercial Insurance Quote
Name of company
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Name of officers/owners
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EIN or social security #
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Phone number
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Mailing address
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Physical address
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Type of company (individual, corporation, partnership, etc)
Your answer
Date business started
MM
/
DD
/
YYYY
Do you need property coverage or just general liability?
Nature of business/description of operations
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Is this a subsidiary of another entity?
Is a formal written safety program in operation?
Any exposure to flammables, explosives, chemicals?
Any past losses?
Any bankruptcies, tax or credit liens against applicant in the last 5 years?
Any coverage denied, cancelled, or non-renewed during the prior 3 years?
Prior insurance info- carrier, policy #, policy type, effective and expiration dates, limits
Your answer
Number of employees
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Gross annual payroll to employees
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Gross annual sales
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Do you use subcontractors?
If yes, do you require they carry insurance?
Do you have any guarantees, warranties, or hold harmless agreements?
Do you lease employees to or from other employers?
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