Small Commercial Account Quote

Agency Information

Agency Name:*

Contact Name:*

Contact's Email*

Agency Phone*

Agency Fax

Risk Information

Type of Risk*

List the type of Risk*

Insured's Information

Entity Type*

Name of Business*

Business Contact Name*

First Last

Phone*

Business Contact Email Address

Mailing Address*

Street Address Address Line 2 City State ZIP Code

FEIN or SSN

Phone*

Expiring Premium

Current Carrier

Expiration Date (mm/dd/yyyy)*

Detailed Description of the Insured's Operations & Other Occupancies*

Insured Interest*

Owner Occupant
Tenant Only

Years in Business*

Owner Payroll (Annual)*

Total Employee Payroll (Annual)*

Total Annual Sales*

Number of Employees*

Desired Coverage Limits

Location #1

Physical Location*

Street Address Address Line 2 City State ZIP Code

County

Protection Class:*

Building Limit: (Replacement Cost)*

Business Personal Property Limit:*

General Liability Limit*

Deductible*

List the Deductible you would like*

Construction Type*

Roof Type*

Flat/Built Up
Asphalt Shingles
Metal

Year Built (yyyy)*

Number of Stories*

Total Square Footage*

Square Footage Occupied by Insured*

Occupancy %*

Square footage for any unoccupied or vacant space*

Any renovation, construction or expansion, currently planned or ongoing*

Yes
No

Description of construction*

Distance to Fire Station*

Distance to Fire Hydrant*

Year Roof Updated (yyyy)*

Year Wiring Updated (yyyy)*

Year Plumbing Updated (yyyy)*

Year Heat/Air Updated (yyyy)*

Sprinkler System*

Yes
No

Fire Alarm System*

Yes
No

Burglar Alarm System*

Yes
No

Circuit Breakers*

Yes
No

Aluminum Wiring*

Yes
No

Payroll at this location*

Sales at this location*

Would you like to add another location?*

Yes
No

Location #2

Physical Location*

Street Address Address Line 2 City State ZIP Code

County

Protection Class:*

Building Limit: (Replacement Cost)*

Business Personal Property Limit:*

Construction Type*

Roof Type*

Flat/Built Up
Asphalt Shingles
Metal

Year Built*

Number of Stories*

Total Square Footage*

Square Footage Occupied by Insured*

Occupancy %*

Square footage for any unoccupied or vacant space*

Any renovation, construction or expansion, currently planned or ongoing*

Yes
No

Description of construction*

Distance to Fire Station*

Distance to Fire Hydrant*

Roof Update*

Wiring Update*

Plumbing Update*

Heat / Air Update*

Sprinkler System*

Yes
No

Fire Alarm System*

Yes
No

Burglar Alarm System*

Yes
No

Circuit Breakers*

Yes
No

Aluminum Wiring*

Yes
No

Payroll at this location*

Sales at this location*

Additional Interests*

Yes
No

Additional Interests Details*

Name of interest	Additional interest address	Type of interest(Mortgage, Loss Payee, Additional insured)	Relevent Location / Equipment (If Applicable)

Please indicate if you are interested in any of these other lines of business for this insured.

(Optional Lines available subject to eligibility)

Work Comp
Business Auto
Umbrella
EPLI
None

File Attachment

Please use this option to attach loss runs, photos, or any other documents that would be beneficial to the underwriter for quoting purposes. -Thanks-

Drop files here or

Max. file size: 16 MB.

Additional Remarks

You may be contacted by a commercial underwriter for additional information.

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