Business Insurance Quote Form

Please fill out the form Completely.

Which Search Engine did you use to find our site?

General Information:

Owner's Name:

DBA:

Business License #:

Tax ID# (FEID) or (SS#):    

Mailing Address:           

City:                        State: CA
County:                    

Zip Code: (Required!)       

Property Address:

(Please complete one form for each property location) 

City:                        State: CA
Zip Code: (Required!)       

Phone:

Email:                     

Are you a:                 (If Partnership or Corporation)

Please list the Names, Title and Percentage of Ownership for each.

How long in business:

How many years experience:

What type of experience:

Nature of Business/Complete Details and
Description of operations:

Property Information:

Do You Own or Lease the Location:
If Own,
Type of Building and Date Purchased:
(i.e. Office, Industrial, Apartment, Residence)

List Number and Type of Occupants in Building:

Construction Type:

# of Buildings at this location:

# of Square Feet for each building:

Year Built:

If built prior to 1980,
detail type and year of
renovations & upgrades:
(i.e. roof, plumbing, electrical, heating, etc.)

Age and Type of Roof:

Does the Building(s) have Circuit Breakers or Fuses?

# of Units in each building:

# of Stories:

Building Sprinklers:

Type of Parking and # of Spaces Available

Is there a Pool?

Is the Pool Fenced?

Is there a Laundry Room?

Is there a Play Ground or Rec. Center?

Type of Security System

Are there bars on windows:    Yes   No

Are they quick-release type:  Yes   No

Approx Current Annual
Gross Receipts/Income:     

Present Insurance Co.:

Insurance Policy #:        

Renewal Date:

Current Premium Amount:

How many years have you been with this insurance company? 

# Losses in Last 5yrs:

Please provide the Date of Loss(s), Cause of Loss(s) and $ Amount:           

    

Reason for Shopping Insurance:

**NOTE: If prior insurance exists, a copy of your policy and a 5 year

Loss History Report will be required.  Please order these items from

your current and prior companies.

Coverages To Quote:

Building Coverage Amount:    Type of Coverage: 

Business Contents Amount:    Type of Coverage:

Business Inventory Amount:   Type of Coverage: 

Property Deductible:       

Loss of Income Coverage:   

General Liability Amount:

Products Liability Amount: 
Professional Liability:

Errors & Omissions (E&O):

Directors & Officers Liab:

Garage Keepers Liability (each vehicle):

Garage Keepers Liability (total occurrence):

Liability Deductible:

Bond Insurance (Type & Amount): 

Earthquake Insurance?

Workers Compensation Insurance:

Workers Compensation Ins?  

If yes or Quote:

Federal Employers Identification Number (FEID):

Current Insurance Company:  Policy #:

Renewal Date:   Business Classification Code:

Any Claims or Losses in the last 5 Years? Yes: or  No:

Please provide the Date, Description and $Amount for each Injury:

Estimated Annual Payroll:  

# of Employees (excluding owners & officers): 

# of Full Time & Average Wage: 

# of Part Time & Average Wage: 

# of Seasonal & Average Wage:  

Please provide a brief description and Job Title 

for each of the above:

Miscellaneous Coverages and Amounts:    



* For Commercial Vehicle Insurance, Please see our Auto Insurance Quote Page.

* For Group Health Insurance, Please see our Health Insurance Quote Page.


Please include a valid email address, phone/fax number,
how you'd prefer to be contacted and the best time and day.
(Note: For a return quote please leave a fax number if available.)