Commercial Insurance Quote General InformationName* First Last Email* Company NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business PhoneFaxCurrent Insurance Company(not agency)Company NamePolicy Expiration Date Date Format: 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 OtherBusiness 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 InformationAddressOccupancy StatusOwnerTenantYear Built% OccupiedSprinklersYesNoConstruction TypeFrameBrick VeneerStuccoMetalConcreteStoriesNumber of BasesmentsSquare FootageBurgler AlarmYesNoBuilding ValueContentsOther Propery (specify)Insurance InformationOtherAnnual Gross Sales(before taxes)Number of EmployeesAnnualized PayrollCost of any Subcontracted WorkLimits Requested$300,000$500,000$1,000,000$2,000,000Describe 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