Professional and Not-for-Profit Organizations
Property & Casualty Request for Quote
Provide Quote By:
E-mail
Fax
Regular Mail
Phone
General Information
How did you hear of our site?
A value is required.
Organization Name
Trade Name
Mailing Address--Street & Suite Number
City
State
Zip
Contact Person
Phone Number
Fax Number
E-mail Address
Web Site URL
Underwriting Information
. . .
Location Address
Enter Location if Different
Organization Type
Same as Mailing
Different from Mailing:
501c Nonprofit
Professional Corporation
Partnership
LLC
Sole Proprietor
For-profit Corporation
. .
Building Occupancy
Owner/Tenant
Year Built
Construction Type
Primarily Office
Primarily Residential
Primarily Retail
Mixed
Not Shown
Tenant
Owner
Frame
Brick/Block & Pitched Roof
Brick/Block & Flat Roof
Metal Building
High Rise
Required--please select
Type of Organization/Description of Operations
Protection--Check All That Apply
Deadbolt Locks
Central Station Alarm
Local Alarm
Grated Doors/Windows
Security Lighting
Sprinkler System
Claim History Last 5 Years for Coverages to be Quoted
Type
Date
Amount
Description
No Claims
Property
Liability
Work Comp
Auto
Other
Property
Liability
Work Comp
Auto
Other
Property
Liability
Work Comp
Auto
Other
Property and Liability Coverages
Quote?
Coverage
Limit Requested
Deductible
General Liability Limit
$1 Million
$2 Million
$3 Million
$5 Million
$10 Million
None
Building Coverage
$1,000
$ 500
$2,500
Contents (Except Computers)
$ 250
$ 500
$1,000
$2,500
Computer Hardware & Media
Same as Above
Heating & A/C Equipment
Included if Selected
Same as Above
Plate Glass--
Linear Feet:
Included if Selected
Same as Above
Optional Coverages
(Flood & Earthquake not available in all states.)
Flood Insurance
Earthquake Insurance
Directors & Officers
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Hired & Non-Owned Auto
Employee Benefit Liability
Harassment & Discrimination
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Additional Interests
(indicate number of each type to be added to the policy)
Landlord/Mortgagee
Lessors of Equipment
Other
Workers' Compensation
Rating Information
No Employees
Employee Class
No. of Employees
Estimated Annual Payroll
Comments
Clerical Office
Full Time Drivers
Other
(Describe in Comments)
Other
(Describe in Comments)
Owners/Officers
Include?
Yes
No
Federal ID Number:
Experience Modification:
None
Automobile
Vehicles
No Owned Autos
No.
Year
Make & Model
Vehicle ID No.
Primary Use
1.
Personal Use Only
Incidental Pickup/Delivery
Regular Pickup/Delivery
Transport Clients/Resident
Other
2.
Personal Use Only
Incidental Pickup/Delivery
Regular Pickup/Delivery
Transport Clients/Resident
Other
3.
Personal Use Only
Incidental Pickup/Delivery
Regular Pickup/Delivery
Transport Clients/Resident
Other
No.
Cost New
Medical Payments
Comp & Collision
Deductible
1.
$1,000
$2,000
$5,000
Yes
None
Comp Only
$100/$250
$250/$250
$250/$500
$500/$500
$500/$1,000
2.
$1,000
$2,000
$5,000
Yes
None
Comp Only
$100/$250
$250/$250
$250/$500
$500/$500
$500/$1,000
3.
$1,000
$2,000
$5,000
Yes
None
Comp Only
$100/$250
$250/$250
$250/$500
$500/$500
$500/$1,000
Automobile Underwriting
Explain any yes answers.
Have any drivers had more than 1 accident or ticket in the last three years?
No
Yes
Has any driver ever been convicted of DUI?
No
Yes
Are any vehicles
not
titled in the name of the business.
No
Yes
Do any drivers have less than 5 years driving experience?
No
Yes
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