Business and Office Owners Insurance Request Office And Business Owner Insurance Quote Request For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.Personal InformationSelect Your StatePlease Note: We only write insurance for these states.SelectMassachusettsAddressWhat is your address? Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name*What is your name? First Last Telephone Number (Business)*What is your business telepone number?Telephone Number (Home)What is your home telepone number?Email Address*What is your email address? FaxWhat is your fax number? Underwriting InformationNature of BusinessWhat is the nature of your business?Is the business a corporation, partnership or sole proprietorship? Corporation Partnership Sole Proprietorship Number of OwnersHow many owners?Please enter a number greater than or equal to 0.Number of EmployeesHow many EmployeesPlease enter a number greater than or equal to 0.Payroll of ownersWhat is the payroll amount of the owners? Payroll of employeesWhat is the payroll amount of the employees? Total Annual Gross ReceiptsWhat is the total annual gross? Business License NumberWhat is the business license number? License TypeWhat is the license type? Years of ExperienceYears of experience in this business?Please enter a number greater than or equal to 0.Years Operated Under Current NameHow many years have you operated under your current business name?Please enter a number greater than or equal to 0.Other Business NamesHave you used any other business names during the past 5 years? Yes No Open 24 hoursIs this business open 24 hours a day? Yes No Deep FryingAny deep frying (food)? Yes No ManufacturingIs there any manufacturing, mixing, re-labeling or repackaging of products? Yes No Propane Tank FillingIs there filling of propane tanks? Yes No Unusual ExposuresPlease describe the nature of your business and ANY unusual exposures.Building & Property InformationTotal Square Footage of Business BuildingWhat is the total square footage of the building your business is in?Please enter a number greater than or equal to 0.Total Square Footage of Business OnlyWhat is the total square footage of your business only?Please enter a number greater than or equal to 0.Square Footage of Customer AreaWhat is the square footage of the customer area only?Please enter a number greater than or equal to 0.StoriesHow many stories is it?Please enter a number from 0 to 99.Ground Floor Square FootageIf two stories, what is the ground floor square footage?Please enter a number greater than or equal to 0.What type of roof covering?SelectArchitectural shinglesAsphalt/Fiberglass shinglesBuilt-up/Tar and gravelClay tileConcrete tileCorrugated steelMineral fiber shakesMission TileRock roofRoll roofingRubber roofSlateTinWood fiber shinglesWood shakeWas the roof updated? Yes No If yes, what year?Year Roof UpdatedPlease enter a number from 1700 to 3000.What is the distance of fire protection?Select1000 ft or less to hydrant & 5 mi or less to fire stationOver 1000 ft to hydrant & 5 MI or less to fire stationOver 5 & up to 10 MI to fire stationOver 10 MI to fire stationBrushIs the building in a brush area? Yes No Storage AreaDo you have a storage area more than 1500 Sq. Ft.? Yes No Smoke DetectorsAre there smoke detectors at this location? Yes No Fire ExtinguishersAre there fire extinguishers? Yes No DeadboltsAre there deadbolts on all doors? Yes No Circuit BreakersAre there circuit breakers? Yes No Is the electrical updated?Electrical UpdateSelectYes, Recently UpdatedNoThermostatically ControlledIs the heading/ air conditioning thermostatically controlled? Yes No CentralIs the heating/ air conditioning central? Yes No Plumbing UpdatedHas the plumbing been updated? Yes No If yes, what year was the plumbing updated?Year Plumbing UpdatedPlease enter a number from 1700 to 3000.Automatic Fire SprinklersDoes the building have interior automatic fire sprinklers? Yes No Theft AlarmIs there a theft alarm? Yes No Fire AlarmIs there a fire alarm? Yes No RestaurantsAre there any restaurants in your building? Yes No Restaurants Next to BusinessAre there any restaurants in the building next to your business? Yes No Claims InformationWere there any losses or claims in the last 5 years?Losses - Claims Yes No What is the date, amount paid and description of each loss or claim?Coverage InformationWhat is the current insurance company? Amount Current CoverageHow much are you paying now? Liability LimitWhat is the liability limit requested?Select$100,000$300,000$500,000$1,000,000Building LimitWhat is the building limit requested? Building DeductibleWhat is the building deductible requested?Select$250$500$1,000$2,500Business Personal PropertyWhat is the business personal property (contents) limit requested? Contents DeductibleWhat is the contents deductible requested?Select$250$500$1,000$2,500Loss of Income CoverageWhat is the loss of income requested? Questions, Comments or Additional CoverageAre there any questions, comments or additional coverage required?CaptchaPrint Form