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Commercial Line Quote Form
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Commercial Lines
Commercial Line Quote Form
Contact / Company Information
Contact Name
*
Email
*
Phone Number
*
Name Insured (Corp)
*
DBA (Name)
Location Address
*
City, State, Zip Code
*
Business Information:
*
Corportation
Partnership
Individual
Description of operations:
If less than 3 years in business, list previous experience:
Federal Tax ID Number
*
Physical Building:
Does Applicant Own Building?
Yes
No
Is Applicant Required by Lease to Insure Building?
Yes
No
Age of Building
Age of Construction
Protection Class
# of Stories
Age of Wiring
Age of Plumbing
Age of Heating
Age of Roofing
Building Limit $
Deductible $
Contents Limit $
Square Footage: Total Building
If Applicant is Tenant, Sq.Ft. of Occupied Space
General Liability:
General Liability Limit
Receipts
Payroll
# of Employees
Claims:
Have their been any claims in the past 5 years; If yes, Describe Loss:
Property Claims
General Liability Claims
Comments
This field is for validation purposes and should be left unchanged.
