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Commercial Package Insurance Quote Request Form


In order for us to properly and fully quote all of our carriers, please provide the following information. If you're able, please email/fax a copy of your full insurance declaration pages to allow us to get you a full and exact rate comparison.  

General Liability
First Name
Required
Last Name
Required
Best contact phone number
Required
E-Mail Address
Required
Best method of contact
Required
What is the full name of the person who referred you to us?
Required
What is your date of birth?
Required
Are you the sole owner? If not, please provide: name and date of birth for each additional owner.
Required
How are you registered?
Optional




When was your business founded?
Required
/ /
How many years of experience do you have?
Required
Who is your current insurance carrier?
Required
How long have you been insured with this company?
Required
What is your FEIN?
Required
Please provide a detailed description of work performed
Required
What % is residential and commercial work?
Required
What are the residential and commercial gross sales/receipts
Required
What is your work radius for commercial and residential?
Required
What is the location address?
Required
Is the mailing and billing address the same?
Required
Do you own or lease the building where you operate?
Required
If you own, how much is the building currently insured for? (Select NA if not applicable).
Required
How many full time employees do you have doing labor?
Required
How many part-time employees do you have doing labor?
Required
What is the annual payroll for these employees?
Required
What is the payroll for subcontracted work, if any?
Required
What is the total expense of rented equipment for the business?
Required
Do you have leased equpiment that needs to be insured? If so, please provide: description, serial # and value.
Required
What is the total cost of tools that cost under $1000 each?
Required
Please provide description, serial # and value of each individual tool that costs more than $1000.
Required
Should the owners be included or excluded from the work comp policy?
Required
What is the payroll for all employee(s) that do non-labor work? What do they do?
Required
Please provide for each vehicle: year, make model, VIN#, value, coverage
Required
Are vehicles rented for the business? What is the total expense?
Required
Do employees use their own vehicle?
Required
Do all owners have a personal auto policy?
Required
Please provide the following information for each driver: name, date of birth, driver's license, driver's license activity.
Required
Please list all claims made on the general liability. Please include: date, description and amount paid out.
Required
Please list all claims made on the property/tool. Please include: date, description and amount paid out.
Required
Please list all loses made on the work comp policy. Please include: date, description and amount paid out.
Required
Comments
Required
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
   
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5075 Cascade Rd SE, Suite 2A | Grand Rapids, MI 49546
Phone: 616-458-7808 | Fax: 616-458-8681
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