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Business Insurance Forms

Commercial Insurance Quote

Fill out the following form as completely as possible. Your request will be handled promptly. (* = Indicate Required Field)

Homeowners Insurance Quote

Date

Prior/Current Insurance Company (if applicable)

Expiration Date

Business Name*

Contact Name*

Address*

Phone*

Alternate Phone

Email*

Entity Type (Individual, LLC, Corporation, etc.)*

FEIN/SSN

Number of Owners/Partners/Officers?

Year Business Started

Number of Employees

Total Annual Payroll

Total Annual Revenue/Sales

Detailed description of operations

Total Cost of Subcontractors

Percentage of subcontractor work

Type of work to be done

Location 1 Address

Year Built

Sq. Footage

# of Stories

Roof Year

Any Building Updates? (describe)

Use

Location 2 Address

Year Built

Sq. Footage

# of Stories

Roof Year

Any Building Updates? (describe)

Use

Location 3 Address

Year Built

Sq. Footage

# of Stories

Roof Year

Any Building Updates? (describe)

Use

Workers' Compensation Limits Requested

# of Full-Time Employees

# of Part-Time Employees

Different Types of Work Done by Employees

Name of Owner/Officer to be included or excluded

DOB

% Ownership

Role/Duties

Name of Owner/Officer to be included or excluded

DOB

% Ownership

Roles/Duties

Name of Owner/Officer to be included or excluded

DOB

% Ownership

Roles/Duties

Any Losses in Past 5 Years? (If yes, list loses below)

Date

Type

Total Paid

Date

Type

Total Paid

Date

Type

Total Paid

How can we help?

Contact Us

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Main Office: 785-331-3607

Fax: 785-331-3850

3801 W 6th Street

Lawrence, KS 66049

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