Quote Sheet

Agent Submitting Form(Required)

General Information

Named Insured:(Required)

Entity Type:(Required)

Mailing Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address

Same as Mailing Address

Physical Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name:(Required)

First Last

Contact Phone:(Required)

Contact Email:(Required)

Do you have a website?

Company Website:(Required)

Years in Business:(Required)

# of Employees:(Required)

Gross Revenue:(Required)

Gross Payroll:(Required)

Does the insured use any 1099?(Required)

If so, are subs required to carry insurance?

Annual 1099 cost:

Does the insured offer employee health benefits?(Required)

Description of Operations:(Required)

Currently Insured?(Required)

If yes, with who?

Any losses in the last 5 years? If so explain all losses:(Required)

Date

Loss Description

Amount paid

Policy Type(Required)

Property

Auto

Workers Comp

General Liability

Property Info

Construction type:

Sq. Ft. Occupied:

# of Stories?

Year Built:

Building Limit: $

Any Basement?

Please specify:

Sq. ft. of Building:

BPP Limit: $

Type of Roof:

When was the last update on the:

Roof:

Wiring:

Plumbing:

Heating:

Auto Information

Does the insured currently have a commercial policy?(Required)

(If so, please provide a copy of the policy. This will allow us to match coverages)

Liability limits:

Coll. Deductible:

Use of vehicle:(Required)

Comp Deductible:

Permanently attached equipment?(Required)

Value of the permanently attached equipment:(Required)

Vehicle List:(Required)

VIN

Garaging Zip Code

Cost New

Radius of Operation

Any Delivery

Drivers List:(Required)

Name

DOB

DL#

DL State

Tickets or accident last 5 years?

If yes to tickets or accidents, please explain:

Workers Comp

FEIN:(Required)

States insured operates in:(Required)

Owners/Officers(Required)

Name

Position/Title

Included/Excluded

% of Ownership:(Required)

Annual Payroll:(Required)

Payroll Splits by Employee Classification:(Required)

Job Classification

Payroll