Business Quote

              IMPORTANT – PLEASE READ BEFORE COMPLETING

          Please note that by submitting this form you understand that coverage is not bound and no policy is issued or in effect. This information is for quoting purpose only. Coverage cannot be bound until such time as we submit a formal application to you and it is signed and returned to our office along with the appropriate down payment.  All information submitted is held in the strictest confidence and is only used for the purposes of providing you an insurance quote.

To provide an accurate quote, please compete all questions as listed below.

BUSINESS INSURANCE QUOTE

Name:*
Mailing Address:*
Street Address (if different from Mailing):
Phone Number: Home: Work:*
  Cell:    
Email Address:*
Web-site:


BUSINESS INFORMATION

  1. Type of organization (Corporation, S Corporation, Individual, Partnership Limited Liability Corp, LLC, Non-profit, )
  1. How many owners, partners or officers?
  1. How many employees, excluding owners, partners or officers?
  1. How many years have you been in business?
  1. What was last years total payroll?
  1. What is this years projected payroll?
  1. What was last years Gross Sales?
  1. What is this years projected Sales?
  1. Describe your normal business activities
  1. Do you use any Sub-Contracting help?
    Yes No

If yes please describe type of sub-contracting help and there percentage of use to the total gross sales.

  1. Have you had any losses or claims in the past 5 years:
    Yes No

    If yes please describe the loss and the amount paid by the company.



Coverage to Quote

Please indicate the desired coverage you would like quoted:

Building Commercial Auto
Contents Liability
Equipment Workers Compensation
Garage Liability    


Please use the space below to add any additional comments or concerns



293 Bedford Street, PO Box 228, Whitman, MA 02382
781-447-5561 Fax: 781-447-1246

236 Quincy Ave, E. Braintree, MA 02184
781-848-4400 Fax: 781-843-0651
info@myinsuranceman.com