Commercial Lines Quote 1Lines of Business2General Info3Location/Class Schedule4Underwriting Questions5Auto6Thank You What policies are we quoting?*Select all the apply. Auto Cyber Farm General Liability Inland Marine Professional Liability Property Workers Comp. How Did You Hear About Us?*ReferralGoogleFacebookOtherWhat other way did you hear about us?* Who Referred You?* First Last Assigned Advisor*Blaine ScottChad BakerJared TollesonMorgan MillerSimon Vacula General InformationName of Entity* Legal Entity*AssociationCorporationGovernment EntityIndividual/Sole ProprietorLimited Liability Company (LLC)Limited Liability Partnership (LLP)PartnershipOtherFEIN Sole Proprietor FEIN NEEDS TO BE IN THIS FORMAT EXACTLY 11-1111111Do you have a DBA?* Yes No Name of DBA* Primary Contact First & Last Name* First Last Primary Contact Cell Phone Number*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do we have permission to text you about policy changes?* Yes No Primary Contact Email* Description of Operations*Annual Sales/Revenue*Year Business Established (YYYY)*The year the current owner established or purchased the business.Number of Managers, LLC Members and Executive Officers*Number of Employees* Location/Class ScheduleLocation Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this the primary premises?*SelectYesNoDescription of Operations for Location*Annual Sales/Revenue (for this location)*Employee Payroll (for this location)*Location Coverage* Building Business Personal Property Business Personal Property Limit*Briefly describe what your business personal property is Year BuiltDo you have a sprinkler system (interior fire suppression)?* Yes No Total Square Footage of the BuildingRoof Type*SelectMetalComposition/Asphalt ShingleSlate or TileSingle Ply MembraneBuilt-UpYear of the Last Roof Replacement?* Underwriting QuestionsDo you currently have insurance?* Yes No Has your insurance been cancelled/declined/nonrenewed in the last 3 years?* Yes No Give the reason* VehiclesVehicle 1 Year, Make & Model* Vehicle 1 VIN* Vehicle 1 Use* Personal Only Personal/Business Business Only Vehicle 1 Ownership Status*Own-Make PaymentsOwn-No PaymentsLeaseVehicle 1 Annual Miles* Aftermarket custom equipment added? If so give value and description.Add a second vehicle?* Yes No Vehicle 2 Year, Make & Model* Vehicle 2 VIN* Vehicle 2 Use* Personal Only Personal/Business Business Only Vehicle 2 Ownership Status*Own-Make PaymentsOwn-No PaymentsLeaseVehicle 2 Annual Miles*Vehicle 2 Aftermarket custom equipment added? If so give value and description.Add a third vehicle?* Yes No Vehicle 3 Year, Make & Model* Vehicle 3 VIN* Vehicle 3 Use* Personal Use Personal/Business Business Use Vehicle 3 Ownership Status*Own-Make PaymentsOwn-No PaymentsLeaseVehicle 3 Annual Miles*Vehicle 3 Aftermarket custom equipment added? If so give value and description.Driver #1* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Driver's License Number* Driver's License State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificRelationship to Insured* Add Second Driver?* Yes No Driver #2* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Driver's License Number* Driver's License State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificRelationship to Insured* Add Third Driver?* Yes No Driver #3* First Last Gender* Male Female Date of Birth* MM slash DD slash YYYY Driver's License Number* Driver's License State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificRelationship to Insured* Need to add more drivers than our form will allow?*If yes, please send your preferred advisor a list of vehicles and drivers. Yes No Comments: Anything else we should know?Upload Current Auto Policy/Declaration Page Drop files here or Select files Accepted file types: doc, pdf, jpg, Max. file size: 500 MB. Upload Declarations Pages from any other polices you might have. Drop files here or Select files Accepted file types: doc, pdf, jpg, Max. file size: 500 MB. CommentsState law requires that the customer be informed that credit information will be used during the quote/application process and that the customer be provided with a copy of the current statement. This information may also be used to provide you with a quote for other insurance products we offer. By submitting this form I certify that I have reviewed the application information contained herein. I verify that the information is true, correct and complete.* I agreeState law requires that the customer be informed that credit information will be used during the quote/application process and that the customer be provided with a copy of the current statement. This information may also be used to provide you with a quote for other insurance products we offer. By submitting this form I certify that I have reviewed the application information contained herein. I verify that the information is true, correct and complete.CAPTCHA
