Business Insurance Quote - Partlow Insurance

Business Insurance

Business Name*

Contact Person's Name:

First Last

Business Address

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

Contact Person's Email*

Business Phone*

Extension

Cell Phone

How May We Contact You?

E-Mail
Business Phone
Cell Phone

Description of Operations:

Current Insurance Carrier:

Date

Umbrella Limit Desired

Property Information

Contents (including inventory):

Square Footage:

Building Replacement Cost (if you own the building)

Type of Construction

Frame
Joisted Masonry
Non-Combustible Masonry
Fire Resistive

Year Constructed

Burglar Alarm

Yes
No

Central Station Alarm

Yes
No

Please list any and all updates that have been made to the roof, electrical, or plumbing of the property and what year they were completed:

Total Annual Sales

Are there any commercial vehicles?

Yes
No

Commercial Auto #1

*Quote is subject to driver eligibility verification.

Year

Make

Model

Vehicle Identification Number (VIN)

*Please Provide any known major traffic violations pertaining to this vehicle

Is there a second commercial automobile?

Yes
No

Commercial Auto #2

*Quote is subject to driver eligibility verification.

Year

Make

Model

Vehicle Identification Number (VIN)

*Please Provide any known major traffic violations pertaining to this vehicle

Is there a third commercial automobile?

Yes
No

Commercial Auto #3

*Quote is subject to driver eligibility verification.

Year

Make

Model

Vehicle Identification Number (VIN)

*Please Provide any known major traffic violations pertaining to this vehicle

Please list additional vehicles if needed

Workers Compensation Information

Class

Code

Total Payroll

Class

Code

Total Payroll

Class

Code

Total Payroll

Experience Mod (if any)

Federal Employers ID Number

Additional Comments