The Insurance Supermarket

 

Fill the below form so that we can determine the amount of coverage you need...


BUSINESS INSURANCE FORM


Basic Address Information

NAME OF BUSINESS CONTACT NAME
ADDRESS
CITY STATE   ZIP
BUSINESS PHONE FAX NUMBER
EMAIL ADDRESS RETURN QUOTE BY:

PRIOR INSURANCE INFORMATION


PREVIOUS INSURANCE YES NO
COMPANY NAME:
POLICY EXPIRATION:

TYPE OF POLICY NEEDED


Commercial General Liability Professional Liability
Commercial AutoCommercial Property
Commercial Umbrella Workers' Compensation Bond Other

Coverage Amount
Limit of Liability Additional Insured Needed?

YOUR BUSINESS


YEARS IN BUSINESS:
NUMBER OF EMPLOYEES:

FULL-TIMEPART-TIME

ESTIMATED 12
MONTH PAYROLL
ESTIMATED GROSS RECEIPTS TWELVE MONTHS

DESRIPTION OF BUSINESS:

Driver Information
(If you need Commercial Auto, please fill out )


NUMBER OF DRIVERS
NAME OF DRIVER
GENDER OF DRIVER
AGE OF DRIVER
TICKETS OR ACCIDENTS
IF YES, EXPLAIN
# YEARS DRIVING
OWN YOUR HOME
CURRENTLY INSURED
IF YES,WITH WHO
ANY CLAIMS
IF YES, EXPLAIN

Automobile Information


NUMBER OF AUTOS [Enter Autos]
YEAR MAKE MODEL VIN# #DRS #CLY 2WD/4WD USE
YEAR MAKE MODEL VIN# #DRS #CLY 2WD/4WD USE
YEAR MAKE MODEL VIN# #DRS #CLY 2WD/4WD USE
YEAR MAKE MODEL VIN# #DRS #CLY 2WD/4WD USE
YEAR MAKE MODEL VIN# #DRS #CLY 2WD/4WD USE

Coverages


VEHICLE LIABILITY LIMITS Bodily Injury Property Damage
UNINSURED MOTORIST LIMITS Bodily Injury Property Damage
PERSONAL INJURY PROTECTION PIP Limit
MEDICAL COVERAGE MEDICAL
PHYSICAL DAMAGE DEDUCTIBLE
Vehicle 1
Comprehensive
Collision
Rental
Towing
Vehicle 2
Comprehensive
Collision
Rental
Towing

Vehicle 3
Comprehensive
Collision
Rental
Towing
Vehicle 4
Comprehensive
Collision
Rental
Towing
Vehicle 5
Comprehensive
Collision
Rental
Towing

Plano General Insurance Agency, 1150 East Park Blvd., Plano, TX 75074 (800)700-3965
Revised: February 25, 2003.