INSURANCE   
  


  COMMERCIAL INSURANCE QUOTE APPLICATION
Fields marked (*) are mandatory.  

Company Name*
Industry Category*
Business Description (no less than 10 words)*
Form of Business*
State Business Located*
Years in Business*
Years Experience in Industry*
Annual Gross Sales (last 12 mo.)*
Estimated Gross Sales (next 12 mo.)*
Number of Locations*
Total Number of Owners,Officers & Directors*
Total Number of Employees*
Annual Gross Payroll (US$ excluding Owners,Officers & Directors)*
Number of Full-time Employees*
Number of Part-time Employees*

               2.Contact
Fields marked (*) are mandatory.
First Name*
Last Name*
State*
Business Phone* ( ) -  ext:
Business Fax ( ) -  -
E-mail*
Have prior insuranceYesNoNew Business
Please Select Insurer's Name
If Other selected Please type in the Insurer Name
With That Insurer for
Estimated Yearly Premium (in US$)
Policy ends on YYYY
Referred By
Please indicate types of insurance you are interested in

               3.Rating Info
Fields marked (*) are mandatory.
Number of Clerical/Outside Sales Employees*
Estimated Clerical/Outside Sales Payroll(USD$)
Number of Drivers*
Estimated Drivers Payroll(USD$)
Excluded Individuals
Name 1:  Title 1: 
Name 2:  Title 2: 
Name 3:  Title 3: 
Name 4:  Title 4: 
Name 5:     Title 5: 
Estimated Excluded Individuals' Payroll(USD$)  
             
  4.Loss History
Fields marked (*) are mandatory.
Calendar Year YYYY
Number of Claims*
Insurer
Total Amt Paid (best est. USD$)
Calendar Year YYYY
Number of Claims*
Insurer
Total Amt Paid (best est. USD$)
Calendar Year YYYY
Number of Claims*
Insurer
Total Amt Paid (best est. USD$)
Calendar Year YYYY
Number of Claims*
Insurer
Total Amt Paid (best est. USD$)

   5.Other Info
Fields marked (*) are mandatory.
Is there an Employee Health Plan provided?YesNo
Have you ever been cancelled?YesNo
Do employees predominantly work from home?YesNo
Do employees travel out of state?YesNo
Any employees with physical handicaps?YesNo
Do you have safety programs?YesNo
Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?YesNo
Is there any unpaid workers compensation premium due or in dispute from you or any commonly managed or owned enterprise?YesNo
Can each driver's state of majority driving time be established through verifiable records/logs?YesNo
Do you have operations in states other than the primary state?YesNo
 

 

HOME    ABOUT US    CONTACT US    HELP

Copyright The California Insurance . All rights reserved.