Commercial Lines Intake Info Commercial Lines Quote Form If you do not have the answer, feel free to skip the question. Step 1 of 5 20% Insured's Name First Last Business Name Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Location Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneFEIN# Type of Insurance needed: General Liability, Property, BOP (GL & BPP: Bis Pers Prop), Commercial Auto, Work Comp, Umbrella, Inland Marine. Type of Business (Corp, Sole Prop, LLC). If Partnership, list partners name & address: Please include a detailed description of operations*Annual Gross Revenue Name Of Business Owner Number Of Full & Part Time Employees Year Business Was Established Years of Experience in Field Please list current or previous carrier & amount of years covered. Please list loses in the last 5 years. Amount of Business Equipment Owned (Tools, Furniture, Equipment, Electronics)Applicable for BUSINESS PERSONAL PROPERTY / INLAND MARINE Commercial Auto QuoteName, Date of Birth, and Drivers License # of all company DriversApplicable for COMMERCIAL AUTOYear, Make, Vin of all company vehicles Commercial BuildingBuilding Owners please provide Year Built, Square Footage, and any updates done to property in the last 10 yearsApplicable for BUILDINGBusiness Tenants “What is the square footage you are leasing for your business. Work CompPlease list number of employees, each employees role, full or part time, amount of annual payroll.Applicable for WORKERS COMPPlease attache a copy of your current insurance!Max. file size: 98 MB.Please provide any information that was not asked that you feel that we should know! Preferred Payment MethodMonthlyAnnualCurrent Monthly Payment
