Pay less for your Business Insurance. Complete the following short form.
It's OK to estimate some values if you are not sure, but providing correct information will allow
your quotes to be processed faster and more accurately.
What most closely matches your business industry?
Brief description of the nature of the business:
(Ex: We install custom cabinets)
Year or time frame business started (OK to estimate):
What is your business legal entity?
Annual revenue (OK to estimate):
Gross annual payroll (OK to estimate):
Coverage Amount:
Total Business Property Contents Value:
Do you have employees in other states:
No
Yes
If so, please list states:
Years of Owner Experience within Industry (OK to estimate):
Employee Information: (Note: For group health insurance, under HIPAA, only full-time employees and owners are elligible for group health insurance benefits.)
Number of Owners (OK to estimate):
Number of full-time employees (OK to estimate):
Number of part-time employees (OK to estimate):
Number of sub-contractors (OK to estimate):
Insurance Types to Quote: (check all that apply)
General Liability Protects the assets of a business in case of a lawsuit related to injury or property damage.
Have you had general liability insurance within the last 30 days? *
No
Yes
Name of Insurance Company:
Expiration date:
Current annual cost? (OK to estimate)
Approximate amount of claims in past 5 years:
Professional Liability / Errors & Ommissions Protects the assets of a business in case of a lawsuit related to errors, or the failure to perform work as promised, as well as other liabilities related to professional work.
Have you had professional liability insurance within the last 30 days? *
No
Yes
Name of Insurance Company:
Expiration date:
Current annual cost? (OK to estimate)
Approximate amount of claims in past 5 years:
Business Owners Policy (BOP) Combines general liability and business property coverage into a single policy.