Payments & Claims

Worker's Comp. Quote Request

Business Type:

Name (Owner - Partner - Corp)

DBA:

Street:

City

State

Zip

Phone Number

Fax

Email Address:

Total # Of Employees

Number of Active Partners

Estimated Annual Payroll

Gross Income

Group Health Insurance?

Insurance Company

Name & Percentage Of Shareholder

Any Seasonal or Handicaped Or Over 35 Yrs or Under 16 Yrs old Employee?

Do Employees Travel Out of State or Work Premonitary At Home?

Are Sub-Contractors Used?

Is Applicant Enganged In Any Other Type of Business?

Years In Business

Number of Officers

Include Officers In Workers Comp?

Federal Employer ID Number

Prior Carrier

Policy Number

Number Of Losses In 4 Years (Need Loss Run)

Any Coverages Cancelled, Declined or Non-renewed in last 3 years?

All Employees With Same Job Duties & Description	Classification	Annual Payroll

Commercial Insurance Quote Request

Insured Name:

Street:

City:

State:

Zip Code:

Email Address:

Phone:

Fax

Please Quote:

Type Of Construction (pls check one):

Info on your Building (if you own the building)

Square Footage of Building:

Square Feet You Occupy:

Current Company (if any):

Number of Stories:

Type of Occupancy:

Building Value:

Year Building Was Upgraded

Contents:

Nature of Business:

Total Annual Sales:

Years In Business:

Do You Import?

Business Contents: (replacement value
including fixtures):

Annual Business Income:

Deductible:

General Liability:
Limits of Liability:
Commercial Umbrella

Comments/Notes:

Motorcycle Insurance Quote Request

FirstName:

LastName:

Date of Birth

Marital Status

Driver Lic #

DL Expire Date

Phone:

Email Address:

Street Address:

Apt/Unit:

City:

State:

Zip:

MilesToWork, 1 Way?

Annual Mileage

# Accident Last 3 yrs

# of Tickets Last 3 yrs

Year of Auto:

Make:

Model:

Prior Insurance Company

How Long Insured

Are You Insured Now?

Last Date of Coverage?

Coverage Limits

Bodily Injury

(In Thousands)

Property Damage

(In Thousands)

Uninsured Motorist

(In Thousands)

Comprehensive Deductible

Collision Deductible

Towing?

Rental

Comments/Notes:

Automobile Insurance Quote Request

FirstName:

LastName:

Date of Birth

Marital Status

Driver Lic #

DL Expire Date

Phone:

Email Address:

Street Address:

Apt/Unit:

City:

State:

Zip:

MilesToWork, 1 Way?

Annual Mileage

# Accident Last 3 yrs

# of Tickets Last 3 yrs

Year of Auto:

Make:

Model:

Prior Insurance Company

How Long Insured

Are You Insured Now?

Last Date of Coverage?

Coverage Limits

Bodily Injury

(In Thousands)

Property Damage

(In Thousands)

Uninsured Motorist

(In Thousands)

Comprehensive Deductible

Collision Deductible

Towing?

Rental

Comments/Notes:

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