Business Liability Quick Quote

Business Name:  

Mailing Address:  

Business telephone:  

Business fax:  

Federal TIN or Social Security number:  

State UBI number:  

Year business started:

Years at current location:  

Inspection Contact Name:  

Inspection Contact Telephone: 

Inspection Contact Cell Phone:  

Inspection Contact E-mail address:  

Nature of business (please describe your business operations):

Business Type:   Individual Partnership Limited-liability partnership Corporation Subchapter-S Corporation Limited Corporation Joint Venture Non-Profit

Is this business a subsidiary of another business? Yes No

        If you answered Yes, please tell us the name of the parent company:  

Does this business have any subsidiaries?  Yes No

        If you answered Yes, how many subsidiaries do you have?   1 2 3 4 or more

        If you answered Yes, are you looking for coverage for the subsidiaries, or just your company?   
        Cover Subsidiaries Too Cover This Company Only

Premises Information

Please fill in the table for every location where you do business. If you have more than three locations, you may submit this portion of the form more than once.

Tell us about your employees:

How many employees do you have?  

How many of your employees get benefits?  

Please select all benefits you currently offer to your employees, even if only some of them are covered.

Medical Insurance
Dental Insurance
Vision Insurance
AD&D or Life Insurance
Short-term Disability
Long-term Disability
Long-term Care (AFLAC type)
Pension Plan
401k Plan Other, please specify

Coverage & Claim History:

Who are your prior insurance carriers? Please list all for the last three years:

Please tell us about the claims against your company: 

During the last five years, have any claims been asserted against your firm?  Yes No

    If Yes, please describe the nature of the claims. This field is unlimited in length. Take all the space you need.

Are you aware of any existing circumstances which may result in a claim not previously reported by you, or shown on a prior insurer's loss report?   Yes No

    If Yes, explain the circumstances and the claim you expect my occur:

Liability coverage amount you are looking for:

$2,000,000

$1,000,000

$750,000

$500.000

$300,000

After pushing the submit button you should see a confirmation screen showing the information you have sent to us. Please check it over and e-mail us with any corrections.