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Commercial Quote Request

You can request a quote for General Liability (GL), Commercial Auto and Commercial Property on this page.

* The only required fields are name and phone number

COMPANY INFORMATION

Contact first name :

Contact last name :

Company name :

Business Entity:

Federal Tax ID Number or SSN if sole prop:

Street address :

Apartment / Suite number:

City :

Zip code :

County :

Work phone number with area code :

* ext :

Home phone number with area code :

Email address :

Nature of business :

If "other" please specify :

Year Business Started :

Years Management experience:

Currently insured with :

Policy number :

Expiration date :

Current annual premium :

Of the following sections, the General Liability (GL) MUST be completed. If you have company vehicles you would like to insure, please complete the commercial auto section. Remember to complete the property information if you own or rent a property you would like to cover.

GENERAL LIABILITY (GL)

Limits of liability :

Number of owners :

Number of employees :

Employee annual payroll :

Do you have subcontractors :

Subcontractors annual payroll :

Gross sales :

Office square feet :

Additional insured :

COMMERCIAL AUTO

DRIVER INFORMATION	DRIVER NUMBER 1	DRIVER NUMBER 2
Driver name (Last, First) :
Driver license number :
Date of birth :
Gender :
Marital Status :
Violations / Accidents the last three years :
.
	DRIVER NUMBER 3	DRIVER NUMBER 4
Driver name (Last, First) :
Driver license number :
Date of birth :
Gender :
Marital Statue :
Violations / Accidents the last three years :
.
VEHICLE INFORMATION	VEHICLE 1	VEHICLE 2
Year :
Make :
Model :
Gross vehicle weight :
Cost new (if known) :

Limits of liability :
Personal injury protection :
Uninsured motorist :
Deductible :
.

	VEHICLE 3	VEHICLE 4
Year :
Make :
Model :
Gross vehicle weight :
Cost new (if known) :

Limits of liability :
Personal injury protection :
Uninsured motorist :
Deductible :

COMMERCIAL PROPERTY

Property address (if different form above) :

City, State and Zip (if different form above) :

County (if different form above) :

Year built :

Property construction :

Property roof :

Wire type :

Property square feet :

Square feet :

Monitored alarm :

I wish to receive e-mails informing me of current events at insurancemakesmesick.com

» IMPORTANT:
I understand insurancemakesmesick.com will attempt to find me the lowest rate with companies we represent. These companies may run underwriting reports in order to provide an accurate quote. By checking this box, you authorize us or the insurance companies to run consumer reports including, but not limited to C.L.U.E., MVR, UDD and credit.