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Insurance
Personal Insurance
Auto Insurance
Homeowners Insurance
Motorcycle Insurance
– View All Personal
Business Insurance
Commercial Property Insurance
General Liability Insurance
Workers’ Compensation Insurance
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Life Insurance
Individual Life Insurance
Final Expense Insurance
Fixed Annuities
Mortgage Protection Insurance
– View All Life
Medicare
Medicare Part C
Medicare Part D
Medigap
– View All Medicare
I Am…
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Single Adults
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Empty Nesters
– View All
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About Us
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Insurance Companies
Insurance Blog
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Online Billing & Payments
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Commercial/Business Insurance Quote
Commercial/Business Insurance Quote
Commercial/Business Insurance Form
* indicates required fields
Business Name
*
Entity Setup
Entity Setup
Corporation
LLC
Sole Prop / Individual
Partnership
Business Owner's Full Name
*
Date of Birth
*
MM slash DD slash YYYY
Business Address
Street Address
Address Line 2
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Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
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Iowa
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Kentucky
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Northern Mariana Islands
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Puerto Rico
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Tennessee
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Utah
U.S. Virgin Islands
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
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Phone Number
*
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Type of Insurance sought:
Type of Insurance sought:
General Liability
Business Owners
Commercial Auto
General Information
What year was the business established?
Describe your business (industry, day to day operations/activities)
Annual gross sales? ($)
List how many full time and part time employees you have. Please do not include owners
*
Full Name
Modality
Add
Remove
Please add any additional employees by clicking the "+" icon to your right. Residents that live in the same address are required to be listed as an excluded driver on your policy if you don't want to cover them.
Total Payroll Amount? ($)
Do you currently have insurance for this business?
Do you currently have insurance for this business?
Yes
No
If yes, what company?
What is the expiration date?
MM slash DD slash YYYY
Have you been canceled in the past 3 years for any reason other than non payment?
Have you been canceled in the past 3 years for any reason other than non payment?
Yes
No
If yes, please explain reason
Do you have any previous losses for this business?
Do you have any previous losses for this business?
Yes
No
Explain them
Business Owners (General + Liability)
How many locations do you have?
Square footage of the space you occupy for you business
Is the building sprinklered? What percentage?
Is the building sprinklered? What percentage?
None
99-90%
90-80%
Less than 80%
Commercial Auto
Do you currently have a General Liability or Business Owners Policy for this business? (Possible discount)
Do you currently have a General Liability or Business Owners Policy for this business? (Possible discount)
Yes
No
Do you have a US DOT number?
Do you have a US DOT number?
Yes
No
If yes, please provide it
Drivers' Information
*
Full Name
Birth Date
License Number
State
Add
Remove
Please add any additional drivers by clicking the "+" icon to your right.
Vehicles' Information
Year
Make
Model
VIN
Add
Remove
Please add any additional vehicles by clicking the "+" icon to your right. If you can attach a copy of your current declarations page, you can skip this step.
Do you or any listed drivers have any accidents, claims, or tickets in the past 5 years?
Do you or any listed drivers have any accidents, claims, or tickets in the past 5 years?
Yes
No
Provide desired coverage limits:
Provide desired coverage limits:
State Minimum Liability 25/50/20
50/100/50
100/300/100
250/500/250
500k Combined Single Limit
750k Combined Single Limit
1 Million Combined Single Limit
If you can attach below a copy of your current declarations page, you can skip this step.
Additional desired coverages:
If you can attach a copy of your current declarations page, you can skip this step.
Uninsured /Underinsured
Medical Payments/PIP
Comprehensive
Collision
Rental Car Reimbursement
Roadside/Towing
Attach Copy of Current Declarations Page
Drop files here or
Select files
Max. file size: 49 MB.
Bundles
Are you interested in bundling other lines of insurance check for bundle discounts?
Homeowners Insurance
Renters Insurance
Boat Insurance
Recreational Vehicle Insurance (Motorcycle, ATV/UTV/Scooters, Golf Carts, Trailers, RV)
Commercial Auto Insurance
Commercial/ Business Insurance
Comments
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