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Business Insurance-All Other
Business Insurance-All Other
Business Insurance Quote Form
Name
(Required)
First
Last
Contact Primary Phone Number
Email
(Required)
Business Legal Name
(Required)
Doing Business As Name or Type "NA"
(Required)
Number of Years in this Business?
(Required)
What type of Insurance do you want us to quote?
Liability
Business Auto
Equiptment
Building
Contents
Umbrella
Workers Compensation
Mailing Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Business Type
(Required)
Corporation
Sole Proprietor
Partnership
LLC
Other
Number of Owners or Officers
(Required)
Describe your Business Opeartion
(Required)
Business Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Current Estimated Gross Annual Sales or Receipts
(Required)
Number of Employees (excluding Owners and Officers)
(Required)
Annual Employee Payroll (Excluding Owners or Officers)
(Required)
Are Subcontractors Used?
(Required)
Yes
No
If Subcontractors are used, do you veritify that they have insurance?
(Required)
Yes
No
No Subcontractors Used
Number of Non Employees 1099s
Annual Cost of Non Employees 1099s
Annual Cost of Subcontractors
Building & Contents Information
Do you own the building?
(Required)
Yes
No
No Subcontractors Used
How much Contents Coverage should we quote?
Construction Type
(Required)
Masonry
Frame
Masonry Non-Combustible
All Metal
Other
Total Building Square Footage?
(Required)
Your Occupied Square Footage
(Required)
Year the Building was Built (est)
(Required)
Age of the Roof
(Required)
Is there a sprinkler system in building?
(Required)
Yes
No
Current Insurance Information
Do you currently have Business Insurance?
(Required)
Yes
No
If yes, please provide name of current Insurance carrier. If no insurance, type "NA."
(Required)
Has there been a lapse in coverage in the last 3 years?
(Required)
Yes, there has been a lapse in coverage.
No, there has not been a lapse in coverage.
Number of Additional Insureds Needed
Has your business had any claims in the past 3 years?
(Required)
Yes
No
Is there anything else that you would like for us to know concerning your up and coming Renewal?
How did you hear about us? Please let us know
(Required)
Signature Required
I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage.
By typing my name warrants my signature.
(Required)
Additional Information Needed
Please note - if the Business is insured, a copy of the policy and claim history will be required. They can be obtained from your current agent by requesting the documents to be sent electronically to you. Thank you for time and we will be in touch with you today unless this is after hours or on the weekend - Debbie Ward and Valerie Moore
Disclosure Statement
By submitting this form, I agree to receive conversational text messages from D. Ward Insurance Services using the contact information provided. For help, reply HELP. Opt-out of receiving text messages at any time by sending STOP. Message and data rates may apply. Message frequency varies.
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