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Home > Business Commercial > Liability and Property Quote Form
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Liability and Property Quote Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

  • Applicant Information
  • Business Information
  • General Liability
  • Property
Company Information
Company Name *
DBA
Type of Business
Mailing Address
Street *
City *
State *
ZIP / Postal Code *
Contact Information
First Name *
Last Name *
Primary Phone Number *
Alternate Phone Number
Fax Number
E-Mail Address *
Website
Number of Owners *
Have any of the owners ever filed for bankruptcy?

Have any of the owners been convicted of a felony?

Location Address
Street *
City *
State *
ZIP / Postal Code *
Nature of Business
Description of Business *
Years in Business
Years of Experience
Gross Annual Receipts *
Total Number of Employees *
Total Annual Employee Payroll *
Project Annual Cost of Subcontracted Work (Includes Labor & Materials)
If yes, what type of work do you sub out?
Coverages
What Limits of Liability are you looking for?
Would you like to include Hired & Non-Owned Auto Coverage?

Would you like to add any Additional Insureds to your policy?


Total #
Would you like to add any Waivers of Subrogation?

Total #
Please select if you need any of the following
Prior Carrier Information
Do you currently have insurance? *
If yes, when does your current policy expire?
What is the name of your current insurance company?
Have you had any claims is the last 5 years?

If yes, Please describe:
Building Information
Year Built *
# of Stories
Select Construction Type
Masonry (Block)
Joisted Masonry-Exterior walls of masonry or fire-resistive materials with combustible floors or roofs (wood)
Frame- Roof, floor, and supports made of combustible material (such as wood). May have veneer made of other materials (such as stucco)
Fire Resistive- Exterior bearing walls/Exterior walls load-bearing portions must be noncombustible materials or masonry. Exterior nonbearing walls/wall panels may be slow burning, combustible, or with no fire-resistance rating
Masonry Non-Combustible-Exterior walls of masonry material with non-combustible or slow burning floors and roofs
Modified Fire Resistive-Exterior bearing walls and load-bearing portions of exterior walls made of non-combustible materials, but exterior nonbearing walls and paneld may be combustible
Additional Building Information
Roof Material *
Area Occupied by Insured (Sq. Ft.)
Roof Update (Year)
Electrical Update (Year)
Plumbing Update (Year)
A/C Update (Year)
Sprinklers

Burglar Alarm

Fire Alarm

Smoke Detectors

Coverages
Building
Business Personal Property
Business Income
Valuation
Actual Cash Value
Replacement Cost
Deductible
Windstorm Hail Deductible
Loss Payee/Mortgagee

Optional Coverages





Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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