Commercial Insurance Quote Request Form Commercial Insurance Form Commercial Insurance Form Your Company InformationWhat's the name of your business?Do you have a DBA name?NoYesWhat is the DBA nameWhen do you want coverage to start?What types of insurance do you need? General Liability Business Property Coverage Errors & Omissions/Professional Liability Workers’ Compensation Cyber Liability Commercial Auto Contact InformationFirst NameLast NamePhone NumberBy checking this box, I consent to receive SMS messages from Ullrich Insurance. I may opt out by replying STOP Yes Email AddressIs the primary contact the business owner?yesnoYour Business DetailsUntitledYears of experience in the industryNumber of employees (not including owners and officers)Do you have a website?YesNoWebsite AddressHow is your business registered?AssociationIndividualLLCLimited PartnershipNon-Medical HomecareCorporationJoint VenturePartnershipTrustS CorporationIs the Association non-profit?YesNoNumber of Executive OfficersNumber of ownersIs the LLC non-profit?YesNoNumber of managers, LLC members and executive officersNumber of partnersNumber of executive officersIs corporation a non-profitYesNoIs the Joint Venture a non-profit?YesNoNumber of PartnersIn a few sentences, describe your business and key business operations(Required)What are the different things that you do?Primary Businesss AddressAddress 1Address 2ZipCity, StateIs your business based out of your home?YesNoIs your mailing address different than your primary business address?Yes, we have a different mailing addressNoWhat is your mailing address?Are there any other business locations?YesNoOther business addressesSales and operationsEstimated annual payroll including ownersEstimated revenue for the next 12 monthsLatest hour that you do business10:00 pm or earler11:00 pm12:00 am1:00 am2:00 amlater than 2:00 amOpen 24 hoursInsurance historyHas your company had any insurance claims in the past 5 years?YesNoWhat is the approximate date of each claim from the past five years, and what happened?Do you currently have General Liability?YesNoHave you had any type of insurance either declined, cancelled or non-renewed within the last three years?YesNoWhat type of insurance was it and what are the specific details of what happened, and when?Do you currently have Errors & Omissions / Professional Liability?YesNoDo you currently have Commercial AutoYesNoCommercial Auto Expiration DateDo you currently have Workers' Compensaation?YesNoNumber of years with prior, consecutive workers' compensation coverageIs any person proposed for coverage aware of any fact, circumstance, or any actual or alleged act, error or omission which might give rise to a claim that would fall within the scope of the proposed coverage?First ChoiceSecond ChoiceThird ChoiceGeneral Liability and PropertyGeneral Liability Limit$1,000,000/$2,000,000$2,000,000/$4,000,000Do you own or do you rent your building?OwnRentYear BuiltCommercial AutoNumber of vehiclesFor each vehicle: 1) year, make, model, 2) type of vehicle (auto, pickup/Van/SUV, commercial truck, trailer), 3) cost new, 4) gross weight 5) is it for personal or commercial use, 6) what is the farthest in one-way miles that the vehile drives from its principal garaging location?Number of driversNote: only a listed driver will be covered by the insurance policyDriver information for EACH driver: 1) First and last name, 2) Date of birth, 3) Drivers license number, 4) Should this driver be included to be covered, 5) Does the driver have a CDL (commercial drivers license), 6) Does the driver require an SR-2 filing, 7) Does the driver have any tickets or at fault accidents in the past 3 years or DUI/DWI within the past 10 years?Does this require state or federal filings? If yes, details:Requires a certificate of insurance to showcoverage for "Any Auto" for client? OR Hired auto liability needed, OR Non-Owned auto needed? If yes, details:
