Type of Business Insurance Needed
Please select the type of business you need insured and then complete the following sections below:
* General Liability Commercial Auto Workers' Comp Property Contractors Equipment Bonds -- Other --

General Information
* Name of Business:
* Inspection Contact Name:
FEIN or Tax ID#:
* Mailing Address:
* City:	State:*   Zip:*
Location Address:
City:	State:   Zip:
* Business Phone:	Fax:
* Contact Email Address:
Business Status:	Individual Corporation Partnership Joint Venture     Years in Business:
New Venture:	Y N         Years Experience: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More than 15

Current Insurance Information
Company Name (not agency):	Premium: $
Effective Date:	Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:	Premium: $
Carrier Name:	Premium: $

General Liability Insurance Coverage
Industry Type:	Retail     Wholesale     Service     Office     Construction     Other
Rating Base:	Payroll:     Gross Rcpts:     Sq Ft:
GL Limits Needed:	$     Per Occ: Agg.
Additional Insured:	# for Year:

Commercial Autobile Insurance Coverage Coverage Information Liability Amount (csl): Select One $300,000 $350,000 $500,000 $600,000 $1,000,000 Uninsured Motorist - Bodily Injury (csl): Select One None $25,000 $50,000 $60,000 $100,000 $250,000 $350,000 $500,000 $1,000,000 Uninsured Motorist - Property Damage: Yes   No Medical: Select One None $500 $1,000 $2,000 $5,000 Hired Auto: Yes   No Non-Owned Auto: Yes   No Comprehensive Deductible: Yes   No       If "Yes", Select One No Coverage $ 250 $ 500 $1,000 Collision Deductible: Yes   No       If "Yes", Select One No Coverage $ 250 $ 500 $1,000 Vehicle Information You can list up to 5 vehicles on this form... reuse this form multiple times for additional vehicles AUTO #1 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Please describe in detail what the vehicle is used for:  If commodity is hauled, please explain: AUTO #2 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Please describe in detail what the vehicle is used for:  If commodity is hauled, please explain: AUTO #3 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Please describe in detail what the vehicle is used for:  If commodity is hauled, please explain: AUTO #4 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Please describe in detail what the vehicle is used for:  If commodity is hauled, please explain: AUTO #5 Year Make Model VIN # Gross Vehicle Weight Cost New Radius (in miles, one way) Vehicle Use lbs. $ Select One Commercial Service Retail Please describe in detail what the vehicle is used for:  If commodity is hauled, please explain:

Workers' Compensation Insurance Coverage
Annual Payroll Code:  (e.g.: $80,000/8810)	$/       $/       $/ $/       $/       $/
Owners:	Included   Excluded
Name:	DOB:     Code:
Name:	DOB:     Code:
Name:	DOB:     Code:
Employer's Liability:

Property Insurance Coverage
Occupancy:	Tenant     Owner Occupant     Lessors Risk
Year Built:	Construction Type:     Sprinklered: Yes No
Alarm Type:	None Local Monitored     Monitored By:
Building Limit:	SF:
Personal Property:  (incl. inventory and   office equipment)	Other:

Contractor's Equipment (Inland Marine) Insurance Coverage
Coverage for your Equipment or Business Personal Property that is being moved around different work sites
Department:	Phone:
Item Description:
Make:	Model:
Item Serial #:	Value: $
Department:	Phone:
Item Description:
Make:	Model:
Item Serial #:	Value: $
Item Description:
Make:	Model:
Item Serial #:	Value: $
Item Description:
Make:	Model:
Item Serial #:	Value: $
Item Description:
Make:	Model:
Item Serial #:	Value: $

Bond Coverage
Bond Category:	Contractors License Bond Surety (Notary) License & Permit Bond Miscellaneous Official Bonds
Bond Description:
Bond Amount:	$     Effective Date:
Name of Obligee:
Obligee Street Address:
City:	State:   Zip:

Other Coverage
Coverage Type Requested:
Coverage Description:
Coverage Amount:	$     Effective Date:

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.