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 Commerical (Business)  Insurance Coverage Quote Request  

      

 

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Business Insurance Quote Request Form

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured:

Coverage Info:

* Business Name   

Type of Business :

*Contract - Full Name:

Describe Operations :

  * Title / Position:   Business Model:
 

Select Type Coverage Below That You Would Like Us To Quote:

*Contact Phone:

 Cell # 

Commercial Auto:

General Liability:

  

   Commercial Building: Business Equipment & Contents

Web URL:

# of Locations:

    *see below

Workers Comp:Umbrella Liability:Professional Liability

Other - Please specify or describe:

*Email:

                 (For Our Agency Use Only)

Fax # :  

 

*Send Quick Quote By : Email Fax Both

 

 

Current Insurance Carriers Name :  

Expiration Date: 

 

 *Business Address:          

 Address:  

City:

 State: Zip :

County:

Mailing Address:          Same as Mailing Address
 Address:
 

City :

State:    Zip: 

County : 

 

Business Information:

 

Years in Business: Number of Employees:

  # Full Time:  # Part Time:

Approx. Annual Payroll $:  Approx. Annual Gross Sales $:

# Vehicles Operated By Your Firm:

  Any Business use of Employee owned vehicles: If yes, how many:

        * If yes, please supply details below in Comments/Remarks section

*Do your rent or own your office/property?Rent Own
 

  Loss Information:

*Have you had any losses or filed a claim in the last five years? Yes  No  If "Yes" Please Provide Brief Description

 

 

  Locations:

Loc # Street City State Zip Code County Number Of Employees

 

Comments/Remarks:

 

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage.  To confirm binding or current policy revisions you must receive a written confirmation for any  new or change in coverage from our agency staff.