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Business Insurance Quote
Are You Frustrated with Agents Misquoting Rates and then Raising the Rate at Time of Sale?
*
Providing the required information below will result in more accurate initial quotes.
General Information
Name of Business:
*
Contact Name:
*
Street Address:
*
City:
*
State:
*
Select One...
Illinois
Missouri
Zip Code:
*
Email Address:
*
Phone Number:
*
Fax Number:
Best Time to Call:
*
AM
PM
Type of Business:
*
Select One...
Individual
Corporation
Partnership
Names of Owners/Coporate Officers
Please list your Owners/Officers separated by the Enter Key
About Your Business
# of full-time employees:
*
# of part-time employees:
*
How long in business:
*
Years
How many locations:
*
Annualized Payroll:
*
$
Annual Sales:
*
$
Please give a brief
description of your
business and clientel:
*
Current Insurance Carriers
Company
Expire Date
Insurance Types
Insurance Types
Types of Coverage
you are interested in:
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Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers´ Compensation
Other
Check All
Uncheck All
Commercial Auto
Automobiles
(include all cars you or your business owns or leases)
Year
Make
Model
VIN
Has any driver listed been convicted of any moving traffic violations in the past 5 years?
Yes
No
(If yes, please add driver histories for each incident. Add button will appear if yes is selected.)
Driver Convictions
Driver
Date
Conviction Type
Liability
Class of Business:
*
Contractor / Building Trades
Contractor / Professional Services
Retail
Professional Office
Truckers
Other
Percentage of any
Subcontracted Work:
*
%
Limits Requested:
*
Select One...
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims
you've had in the past
5 years:
Property/Premises Information
Location Name
Address
Workers Compensation
Federal ID Number:
*
If known, describe
any claims you've had
in the past 5 years:
Rating Information
Classification Description
*
(By Employee Group)
Annual Payrol
(By Group)
Do you want to include Owners/Officers:
*
Yes
No
Comments/Other Information:
Contact us:
1913 S. Illinois St.
Belleville, IL 62220
Phone:
618-236-1500
618-281-1700
Fax:
618-236-1501
Email: info@NowakInsurance.com
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