Commercial Insurance Quote General InformationName* First Last Email* Company Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business PhoneFaxCurrent Insurance Company(not agency)Company Name Policy Expiration Date MM slash DD slash YYYY Current Insurance Coverages Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Group Life Professional Liability Workers' Compensation Other Other Business InformationNumber of Full-time EmployeesNumber of Part-time EmployeesHow long in business(Years)How many locations?Please give a brief description of your business and clienteleProperty/Premises InformationAddress Occupancy Status Owner Tenant Year Built% OccupiedSprinklers Yes No Construction TypeFrameBrick VeneerStuccoMetalConcreteStoriesNumber of BasesmentsSquare FootageBurgler Alarm Yes No Building ValueContents Other Propery (specify)Insurance InformationOther Annual Gross Sales (before taxes)Number of EmployeesAnnualized Payroll Cost of any Subcontracted Work Limits Requested $300,000 $500,000 $1,000,000 $2,000,000 Describe any claims you've had in the past 5 yearsAdditional CommentsDisclaimer Notice The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
James F Tullis & Associates 1645 San Marco Boulevard Jacksonville, Florida 32207 Phone: 904-396-2041 Toll Free: 800-874-4407 Fax: 904-396-2874 Contact us