COMMERCIAL INSURANCE QUOTE APPLICATION |
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Fields marked (*) are mandatory. |
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Company Name* |
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| Industry Category* |
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| Business Description (no less than 10 words)* |
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| Form of Business* |
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| State Business Located* |
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| Years in Business* |
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| Years Experience in Industry* |
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| Annual Gross Sales (last 12 mo.)* |
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| Estimated Gross Sales (next 12 mo.)* |
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| Number of Locations* |
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| Total Number of Owners,Officers & Directors* |
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| Total Number of Employees* |
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| Annual Gross Payroll (US$ excluding Owners,Officers & Directors)* |
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| Number of Full-time Employees* |
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| Number of Part-time Employees* |
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2.Contact
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| First Name* |
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| Last Name* |
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| State* |
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| Business Phone* |
(
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ext:
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| Business Fax |
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-
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| E-mail* |
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| Have prior insurance | YesNoNew Business |
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| Please Select Insurer's Name |
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| If Other selected Please type in the Insurer Name |
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| With That Insurer for |
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| Estimated Yearly Premium (in US$) |
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| Policy ends on |
YYYY
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| Referred By |
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| Please indicate types of insurance you are interested in |
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3.Rating Info
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| Fields marked (*) are mandatory. |
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| Number of Clerical/Outside Sales Employees* |
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| Estimated Clerical/Outside Sales Payroll(USD$) |
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| Number of Drivers* |
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| Estimated Drivers Payroll(USD$) |
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| Excluded Individuals |
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| Name 1:
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Title 1:
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| Name 2:
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Title 2:
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| Name 3:
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Title 3:
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| Name 4:
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Title 4:
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| Name 5:
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Title 5:
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| Estimated Excluded Individuals' Payroll(USD$) |
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4.Loss History |
| Fields marked (*) are mandatory. |
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| Calendar Year |
2007 |
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| Number of Claims* |
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| Insurer |
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| Total Amt Paid (best est. USD$) |
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| Calendar Year |
2006 |
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| Number of Claims* |
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| Insurer |
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| Total Amt Paid (best est. USD$) |
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| Calendar Year |
2005 |
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| Number of Claims* |
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| Insurer |
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| Total Amt Paid (best est. USD$) |
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| Calendar Year |
2004 |
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| Number of Claims* |
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| Insurer |
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| Total Amt Paid (best est. USD$) |
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5.Other Info |
| Fields marked (*) are mandatory. |
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| Is there an Employee Health Plan provided? | YesNo |
| Have you ever been cancelled? | YesNo |
| Do employees predominantly work from home? | YesNo |
| Do employees travel out of state? | YesNo |
| Any employees with physical handicaps? | YesNo |
| Do you have safety programs? | YesNo |
| Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? | YesNo |
| Is there any unpaid workers compensation premium due or in dispute from you or any commonly managed or owned enterprise? | YesNo |
| Can each driver's state of majority driving time be established through verifiable records/logs? | YesNo |
| Do you have operations in states other than the primary state? | YesNo |
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