To start a Commercial Insurance (liability), or Commercial Property Insurance Quotation, please fill out the following form.

Please Note: We will contact you via telephone for any personal, security-sensitive information, as well as any other information we need to further process the quote.

Type of Commercial Coverage you are looking for (required)

Employee Life, Accidental & Disability InsuranceCommercial Auto InsuranceCommercial Recreational Vehicle Insurance (including RV/Mobile Office, Motorcycle, ATV)General Liability InsuranceRental Property InsuranceOther Commercial Property InsuranceFlood InsuranceRenters InsuranceGeneral Umbrella Insurance PoliciesWorkers Compensation InsuranceLiability Insurance for my ChurchBonds

Your Full Name (required):

Company Name (required):

Your Email Address (required):

The best Telephone Number to reach you at (required):

The Best TIME to reach me by telephone:

The Primary Address of the business (required):

Number of years at this address (optional):

Mailing Address (if different from above):

Federal EIN Number:

Business Type:
RetailWholesaleService-BasedManufacturingNon-ProfitFood Service/RestaurantOther

Description of the Business Activities (required):

Desired/Required Amount of General Liability Coverage (if applicable):

Total Annual Payroll Amount for General Liability or Workers Compensation Quotations

Annual Payroll Exposure (if known)

Other Liability Exposure (if known)

Do you have current/previous coverage? If so, how long?

Have you ever been canceled, denied or have your insurance lapse?
yesno

Please explain any lapse, cancelations in your previous coverage (if applicable):

When would you like coverage to begin




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The following pertains only to Commercial Auto Policies - Please Skip Over if you are looking for other types of Commercial Coverage


Please list any additional insured drivers, their position in your company, and their current ages:


Vehicle Information

Vehicle Number 1

Year, Make, and Model:

Vehicle's estimated current value?

Vehicle VIN number:


Vehicle Number 2

Year, Make, and Model:

Vehicle's estimated current value?

Vehicle VIN number:


Vehicle Number 3

Year, Make, and Model:

Vehicle's estimated current value?

Vehicle VIN number:

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Have you (or your company if applicable) had any traffic tickets, comprehensive insurance claims, or accidents in the past 5 years?
yesno

If you answered "Yes" to the above question, when was the last traffic violation, accident and/or comprehensive claim?



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The following pertains only to Commercial Life Insurance Policies - Please Skip Over if you are looking for other types of Commercial Coverage

What type of Life Insurance are you looking for (if you know):
Whole Life (Full Term)Term Life (5 year increments)Child (0-17 years old)Adult (18-70 years old)I don't know what I need

Number of Employees

Desired Coverage Amount per Employee



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The following pertains to Commercial Property Coverage Policies. Please Skip Over if you are looking for other types of Commercial Coverage.

Have you ever been cancelled or denied Insurance for your Commercial Property before?
YesNo
If Yes, please explain When and Why (if known):

Do you own, rent or lease the property (or properties)?
OwnRentLease

Is the business within 5 miles of a Fire Department?
YesNo

Is the building (or buildings) within 1,000 feet of a Hydrant?

What is the Name of the Fire District or Nearest Local Fire Department(s)?

Number of Locations your business operates within:

Number of Buildings per location:

**We may contact you about further dimensions and additional information about your property.**


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Building 1

Requested Coverage Amount:

Amount of Coverage for Contents:

Deductible Desired:
5001,0001,7502,500

Style of Building:

Year Built:

Construction Type:
BrickFrameLogConcreteOtherDon't Know

Does it have a Basement?
No BasementFinished BasementUnfinished BasementCellar

Type of Roofing:
ShingleMetalWoodFlatRubberOther

Heat Type:
Central Gas FurnaceCentral Electric FurnaceCentral Oil-burning FurnaceElectric Heat-PumpBaseboard HeatingFireplace OnlyWood Burning StoveWood Burning FurnaceCeiling HeatingFloor FurnaceRadiant Floor Heat (Oil or Water)

Active Fireplace?
YesNo

Heating Source:
GasWoodOil

Number of Stories:
1234

Square Footage:

Number of Rooms (excluding Bathrooms):

Number of Baths:

Number of Porches:

When was the Heating and Air Conditioning last updated?

When was the Roofing last updated?


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Building 2

Requested Coverage Amount:

Amount of Coverage for Contents:

Deductible Desired:
5001,0001,7502,500

Style of Building (shop; retail; etc):

Year Built:

Construction Type:
BrickFrameLogConcreteOtherDon't Know

Does it have a Basement?
No BasementFinished BasementUnfinished BasementCellar

Type of Roofing:
ShingleMetalWoodFlatRubberOther

Heat Type:
Central Gas FurnaceCentral Electric FurnaceCentral Oil-burning FurnaceElectric Heat-PumpBaseboard HeatingFireplace OnlyWood Burning StoveWood Burning FurnaceCeiling HeatingFloor FurnaceRadiant Floor Heat (Oil or Water)

Active Fireplace?
YesNo

Heating Source:
GasWoodOil

Number of Stories:
1234

Square Footage:

Number of Rooms (excluding Bathrooms):

Number of Baths:

Number of Porches:

When was the Heating and Air Conditioning last updated?

When was the Roofing last updated?


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Building 3

Requested Coverage Amount:

Amount of Coverage for Contents:

Deductible Desired:
5001,0001,7502,500

Style of Building:

Year Built:

Construction Type:
BrickFrameLogConcreteOtherDon't Know

Does it have a Basement?
No BasementFinished BasementUnfinished BasementCellar

Type of Roofing:
ShingleMetalWoodFlatRubberOther

Heat Type:
Central Gas FurnaceCentral Electric FurnaceCentral Oil-burning FurnaceElectric Heat-PumpBaseboard HeatingFireplace OnlyWood Burning StoveWood Burning FurnaceCeiling HeatingFloor FurnaceRadiant Floor Heat (Oil or Water)

Active Fireplace?
YesNo

Heating Source:
GasWoodOil

Number of Stories:
1234

Square Footage:

Number of Rooms (excluding Bathrooms):

Number of Baths:

Number of Porches:

When was the Heating and Air Conditioning last updated?

When was the Roofing last updated?




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Please include any Additional Information that you feel would help expedite your quote:

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