Company Name: Email: Home Number: Address: City: State: Zip: Fax: Form Protection Code:* Please, enter the text shown in the image into the field below. Disclaimer Notice: The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and down payment. Business Quote General Information Contact Name: Choice 1 Choice 1 Business Information # of Full-Time Employees: # of Part-Time Employees: How long in Business? (yes): How many locations?: Please give a brief description of your
business and clientele: Property/Premises Information Current Insurance Company Company Name: Policy Expiration Date: (not agency) Current Insurance Coverages Current Coverages Yes No Yes No Bond Commercial Auto Yes No Yes No Commercial Liability Commercial Property Yes No Yes No Commercial Umbrella Directors & Officers Liability Yes No Yes No Disability Group Health Yes No Yes No Group Life Professional Liability Yes No Workers Compensation Other Address: Occupancy Status: Year Built: % Occupied: Sprinklers: Construction Type: Stories: # Basements: Sq. Footage: Burglar Alarm: Building Value: Contents: Other Property (Specify): Owner Tenant Yes No Please Choose Frame Brick Veneer Stucco Metal Concret Yes No Insurance Information Other: Annual Gross Sales (before taxes): Number of Employees: Annualized Payroll: Cost of any Subcontracted Work: Limits Requested: $300,000 $500,000 $1,000,000 $2,000,000 Describe any claims you've had
in the past 5 years: Additional Comments: