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Commercial Business Insurance Quote Form
Business Name:
Email Address:
Phone Number:
Fax Number:
Contractors Number:
Business Website:
Classification:
Address of Business:
City:
Ca
Zip:
Entity Type
Sole Proprietor
Corporation
LLC
Partnership
Other
FEIN Number:
Years in Business:
Years of Prior Experience:
Type(s) of Insurance Needed:
General Commercial Insurance
Commercial Auto Insurance
Workers Compensation
Number of Locations:
Please Provide Addresses for Additional Locations
State(s) of Operation:
Name(s) of Owner(s)/Officer(s):
Describe Your Operation:
Annual Receipts/Sales - Current Year:
Previous Year:
Do You Have Employees:
Yes
No
If Yes, How Many:
Annual Payroll:
Do you offer Group Health Insurance to your employees:
Yes
No
If Yes, Name of Carrier:
Do you have Workers' Compensation in force:
Yes
No
N/A
If yes, please provide the following: Carrier Name, Expiration Date, Premium:
Do you currently have General Liability/Property Insurance coverage:
Yes
No
If yes, please provide the following: Carrier Name, Expiration Date, Premium:
How many years of prior, uninterrupted insurance coverage:
Have you been involved in or aware of any claims:
Yes
No
If yes, please explain:
Additional Questons for Commercial Auto Insurance
Limits Needed:
Liability:
Medical Payments:
Uninsured Motorist:
Comprehension:
Collision:
Vehicles - Please include Year, Make/Model, Body Type, Cost New, Garage/Zip, GVW/GCW:
Driver Information - Please include Name, Drivers License #, DOB:
CA Number (If Applicable):
Additional Questons for Workers Compensation Insurance
Safety Plan:
Yes
No
Safety Meetings:
Yes
No
How Often:
Provide Medical Coverage:
Yes
No
If you were referred to Barthold Insurance by someone, please list name of person who referred you: