Automotive

  • Applicant
  • Business
  • Business Location
  • Policy
  • Losses
  • Coverage
  • Miscellaneous
  • Finish

Applicant

First Name *
Last Name *

Where should we send your quote?

Email *
Phone *

Please fill all the mandatory questions.

Business

Business Info

Business /​ Company Name *
Years in Business
DBA (If Applicable)
FEIN # (If Applicable)
Organization Type *

Internal

Type of Business *
Specify Business *
Number of Full Time Employees
Number of Part Time Employees
Annual Payroll *
Estimate Annual Sales *
Description of Business
Number of Vehicles stored overnight?
What is the average value of each car?
What would be the maximum value of all cars stored at night in your custody ?

Please fill all the mandatory questions.

Business Location

Building Info

Business Address
Address *
City *
State *
Zip Code *
Mailing Address
Address *
City *
State *
Zip Code *
Business Address
Construction Type
Roof Type
Total Square Feet
Year Built
Number of Stories
Number of Basement
Specify the Business

Building Renovations

Please choose all that apply
Year Wiring was renovated *
Year Heating was renovated *
Year Plumbing was renovated *
Year Roofing was renovated *

Security

Burglar Alarm Type
Percent of Protection that are sprinklers
Type of Safety Program *

Please fill all the mandatory questions.

Policy

History

Reason for Cancellation

Prior Carrier

Name of Carrier *
Expiration Date of Policy

Please fill all the mandatory questions.

Losses

loss 1

Loss Details

Type of Loss *
Date of Loss *
Amount of Loss
Details of Loss *

Please fill all the mandatory questions.

Coverage

Property Coverage

Building Limit *

(Sq ft. * Cost per Sq ft.)

Deductible *
Business Personal Property
Personal Property of Other (If Any)
Actual Loss of Income /​ Rent
Specify loss income/rent *

Additional Property Coverage

Building Ordinance Coverage *

Liability Coverage

Occurrence /​ Aggregate
Product Liability

(Same as Aggregate Limit)

Please fill all the mandatory questions.

Miscellaneous

Do any of the following apply to your business?

Please fill all the mandatory questions.



Thank you!

Your details has been submitted successfully.




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