Need a quote right away? Answer these basic questions about your business & fax/Email to our Office:

Your Personal Name & Title in the Business:
Name of business:
Type of entity: (sole proprietor, llc, corp.)
# of owners:
Address of business:
Mailing address:
Location address of business:
Email:
Phone:
Social and FEIN:
Years in business:
Prior Insurance History:
Years of experience in this particular industry:

Tell me a little bit about your business and your services:

Do you have a website?

Walk me through your day to day operations:

Tell me the types of coverages or concerns you have that you would like to be protected against:

Tell me about the coverage that you have in place now , if you have had any coverage in place. (we will need a copy of the declarations page emailed to us)

In a one year period from this month now, until this time next year…..what is your projection for gross money before any expenses that your company will bring in?

Of that money, what do you pay out for your workers? Subdivide that payroll into the duties the workers perform (Your workers are w2 workers or 1099 workers whereby you do not have a certificate that they have their own insurance) :

What do you pay out for true subcontracted out companies that have their own insurance? Of the companies you “sub” work out to – What types of service are you sub’g out?

Do you own any additional businesses, Corp’s, or does this business perform more than the operations explained so far?

How much value do you have in tools & equipment?

How much value do you have in office contents or your contents you use in your business?

Do you own a building or a vehicle that you use in the business?

Do you have any third parties asking for the insurance? What specific requirements do they have?

ONCE COMPLETE, PLEASE CALL US AT 210 508 1659 AND OUR OFFICE WILL INSTRUCT YOU ON WHERE TO SEND THIS FORM. THANK YOU