Business Quote

General Information
Contact Name *
Email *

Business Name
Address
City
State
Zip
Business Phone
Fax
Current Insurance Company
Do you currently have coverage? Yes  No
Current Insurance Company Name
Policy Expiration Date
Current Insurance Coverages
Current Coverages/ Requested Coverages Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Insurance Information
Annual Gross Sales: (before taxes)
Annualized Employee Payroll Amount
Cost of any Subcontracted Work
Limits Requested $1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
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 a down payment.

FOR ALL YOUR INSURANCE NEEDS 

583 105th Ave N #2,
Royal Palm Beach, FL 33411

Phone:(561) 966-8883

Fax: (561) 964-8885


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