Crocker Insurance Associates - Personal and Business Insurance

Commercial Insurance Request for Quote

Salutation
First Name
Last Name
Company Name
Physical Address
City, State, Zip
Telephone Number		- - Ext.
Fax Number
Email (must be valid email address)
Type of business
Years in business
Do you lease or own your buidling?
Square footage
What is approximiate replacement cost of the building?
What is the construction of the building?
Type of roof
Would you like to cover tools or equipment?
If yes, what is the total replacement cost?
If you have elected to cover equipment, please list each item and its replacement cost.
What are your current limits of liability?
Number of full-time employees
Number of part-time employees
Estimated annual payroll
% of Work Sub-Contracted and type (If applicable)
If you use sub-contractors, are your sub-contractors insured with limits equal to the limit that you carry?
If not, please explain
Estimated annual sales
List any one who will require a certificate of insurance and their address.
Do you need a quote on optional coverage? (Check all that apply)		Business Auto Worker's Compensation Umbrella Health Other (Please list)
Do you require a bond line?

Applicant must check this box in order for application to be processed.		State Law requires that we notify you of the use of credit for the determination of insurance rates. The information used may be derived in part from information from your credit file. All credit information is kept in strict confidence and is used for the sole purpose of obtaining insurance underwriting information. All claims and violation data will be verified. Failure to disclose this information may result in an increase in premium, or in some cases declination of coverage.
		Additional information may be required to quote the requested coverage.

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Commercial Insurance Request for Quote