Welcome to Rosier Insurance Group, Inc.

Business Insurance Quote Request

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Information

Name:

Address:

City:

State:

Zip:

Day Phone:

Eve. Phone:

Beeper:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Current Policy Information

Agent:

Insurance Company:

Policy Number:

Policy Expiration Date:

Tell us about your business

How many years in business?

How many years at current location?

Do you own or rent office space?

Number of locations:

Annual Gross Revenue

Annual Payroll (estimated):

Describe business:

Amount of Insurance Desired:

Tell us about your building

Year Built:

Construction:

Stories:

Square feet

Has building been rewired?

Yes No

If yes, what year?

New Plumbing?

Yes No

If yes, what year?

New Roof?

Yes No

If yes, what year?

Roofing Material used:

Central Heat and Air?

Additional Information Section

In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc.