Complete the
following information if you would like to obtain a
commercial Insurance quote. Remember, this is not an
application, one will be sent to you if coverage is
requested.All information
provided on this information sheet is confidential and
will be used solely for the purpose of quoting your
commercial insurance.
Personal Information
What is your name?
Last
First
Middle
What is your business
name?
Business Name
County Information
County
What is your address?
Street
City
State
Texas
Zip
What is your telephone
number?
Home
Business
What is your fax number?
Fax
What is your email
address?
Email
Confirm your email
address?
Email
Underwriting Information
What is the nature of
your business?
*** Required -
Business Description
Nature of Business
Is the business a
corporation, partnership or sole proprietorship?
Corporation
Partnership
Sole Proprietorship
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll
amount of the owners?
Required
Payroll of Owners
What is the payroll
amount of the employees?
Required
Payroll of Employees
What is the total annual
gross?
Required
Total Annual Gross
Receipts
What is the business
license number?
Business License
Number
What is the license
type?
License Type
Years of experience in
this business?
Required
Years of Experience
How many years have you
operated under your current business name?
Years Operated Under
Current Name
Have you used any other
business names during the past 5 years?
Other Business Names
Yes
No
Is this business open 24
hours a day
Open 24 Hours
Yes
No
Please describe the
nature of your business and ANY unusual exposures.
Unusual Exposures
Building & Property
Information
Year built?
Year built
What is the total square
footage of the building your business is in?
Total Square Footage
of Business Building
What is the total square
footage of your business only?
Total Square Footage
of Business Only
What is the square
footage of the customer area only?
Square Footage of
Customer Area
How many stories is it?
Stories
Select
1
2
If it's two stories,
what is the ground floor square footage?
Ground Floor Square
Footage
Claims Information
Where there any losses
or claims in the last 5 years?
Losses - Claims
Yes
No
If yes, what is the
date, amount paid and description of each loss or claim?
Coverage Information
Surname
What is the current
insurance company?
How much are you paying
now?
Amount Current
Coverage
What is the liability
limit requested?
Liability Limit
Select
$100,000
$300,000
$500,000
$1,000,000
What is the building
limit requested?
If no coverage is
required for your building - Please type in N/A or 0
Building Limit
Do you require Coverage
for the building?
Yes/No
What is the building
deductible requested?
Building Deductible
Select
$250
$500
$1,000
$2,500
What is the business
personal property (contents)
limit requested?
Business Personal
Property
Do you require Coverage
for the business personal property?
What is the contents
deductible requested?
Contents Deductible
Select
$250
$500
$1,000
$2,500
What is the loss of
income requested?
Loss of Income
Coverage
Are there any questions,
comments or additional coverage required?
Questions, Comments or
Additional Coverage
