| 1) |
How many total employees currently work for your company? [required] |
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(Use numbers only -- e.g., 10, not ten.) |
| 2) |
What is the breakdown of these individuals? [required] |
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Full or part-time Employees:
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Sub-contractors/Consultants:
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| 3) |
What kinds of business insurance are you interested in purchasing? [required] |
Help
me answer |
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General Liability
Business Owner's Policy (BOP)
Property
Workers' Compensation
Professional Liability / Errors & Omissions (E&O)
Directors & Officers (D&O)
Business Automobile
Marine
Umbrella (Supplemental Liability)
Business Interruption
Key Person Life
Business Travel
Other (please specify):
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| 4) |
What is your business entity (legal entity)? [required] |
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| 5) |
How many years has your company been in existence? [required] |
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| 6) |
What is the approximate annual revenue of your business? [required] |
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Under $100,000
$100,000-$500,000
$500,000-$1,000,000
$1,000,000-$10,000,000
$10,000,000+ |
| 7) |
How many years of experience does the senior executive of your company
have in your industry? [required] |
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| 8) |
Is this coverage needed for a one-time or seasonal event? [required] |
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Yes
No
Not Sure |
| 9) |
When would you like your plan to take effect? [required] |
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ASAP
Within one month
In one to two months
More than two months
When my current policy expires |
| 10) |
How would you best describe your company’s industry? [required] |
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| 11) |
What is the five digit ZIP code for your office location? [required] |
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(We only serve U.S. businesses at this time.) |
| 12) |
What is your e-mail address? [required] |
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Why we need your email address |
| 13) |
If you currently have business insurance, please indicate the following: |
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| 14) |
Please describe any additional requirements or specifics about your
insurance needs (e.g. your current situation and how much coverage you want).
The more information you can provide here, the more accurately out vendors
can be in providing quotes. |
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Note: There is a 1,000 character limit for this answer. |
