Auto Insurance, Home Insurance, Life Insurance and more from Barthold Insurance

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 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: