Business Insurance Quote Form

For a business insurance quotation, please fill out the following form and click the submit button. An agent will contact you within 24 hours.
Questions? Please contact us. If you would like a personal insurance quote, please click here.

General Information About Your Company: Legal name of business Name Street City Postal Code Contact person Telephone Fax Email Website How many years in business Type of industry Description of business (no more than 250 characters please)
# of Employees - full time part time

Line(s) of insurance for which I would like a quote: Automobile General Liability Property Workers Compensation Other (e.g. professional liability, EPLI, D&O, Bond, etc) Requested Coverage Effective Date

For an accurate quote, please be sure to click on to expand and complete the corresponding sections.

Automobile Insurance

General Liability

Do you currently have General Liability insurance? Yes No With whom? Please select a liability coverage limit (per occurence/aggregate) Umbrella limit Annual revenues Annual payroll Annual cost of subcontractors Any General Liability losses in the past 5 years? Yes No If yes, please describe (include date of loss and total amount paid)

Property Insurance

Please contact us at 800-824-4455 if you have more than three locations.
Do you currently have property insurance?
Yes No With whom?

Location 1

Location 2

Location 3

Street
Street
Street

City
City
City

Postal Code
Postal Code
Postal Code

Do you own or lease this location? Yes No Do you own or lease this location? Yes No Do you own or lease this location? Yes No

If you OWN the building, how much do you currently have it insured for? (if this is a new purchase then please enter 0)
If you OWN the building, how much do you currently have it insured for? (if this is a new purchase then please enter 0)
If you OWN the building, how much do you currently have it insured for? (if this is a new purchase then please enter 0)

If you LEASE the building, what is the value of your tenant improvements?
If you LEASE the building, what is the value of your tenant improvements?
If you LEASE the building, what is the value of your tenant improvements?

Please list other occupants in the building (if any)
Please list other occupants in the building (if any)
Please list other occupants in the building (if any)

What is the total value of your business personal property at this location? (furniture, fixtures, equipment, machinery, stock, etc)
What is the total value of your business personal property at this location? (furniture, fixtures, equipment, machinery, stock, etc)
What is the total value of your business personal property at this location? (furniture, fixtures, equipment, machinery, stock, etc)

Square footage of this space/building
Square footage of this space/building
Square footage of this space/building

Please select building construction material
Please select building construction material
Please select building construction material

Year of construction
Year of construction
Year of construction

If the building is over 25 years old, please describe any renovations
If the building is over 25 years old, please describe any renovations
If the building is over 25 years old, please describe any renovations

Any losses at this location in the last 5 years?
Yes No Any losses at this location in the last 5 years?
Yes No Any losses at this location in the last 5 years?
Yes No

If yes, please describe (include date of loss and total amount paid)
If yes, please describe (include date of loss and total amount paid)
If yes, please describe (include date of loss and total amount paid)

Does the building have an alarm? Yes No Does the building have an alarm? Yes No Does the building have an alarm? Yes No

Is the building sprinklered? Yes No Is the building sprinklered? Yes No Is the building sprinklered? Yes No

Workers Compensation

Do you currently have workers compensation insurance? Yes No If known please provide your Experience Mod and ARAP State in which your business is domiciled Federal Employer Identification Number
Please provide details on employee(s) (excluding corporate officers & out of state employees). Two common employee categories are provided; please enter additional categories as appropriate. This information is available on your current workers compensation policy.

Class Code (if known)

Description of Employees

# of employees

Annual payroll amount

Please list all states in which you have other employees
Do you wish to include or exclude corporate officers? Include Exclude
If including corporate officers, please complete the table below:

Class Code (if known)

Description of officer's role

# of officers

Annual payroll amount

Please select an Employer's Liability coverage limit:
Other (e.g. professional liability, EPLI, D&O, Bond, etc). Please provide a description of the additional type(s) of insurance for which you would like information (be sure to include specific types of insurance and limits): [this field should accept approximately 250 words]

Submitting an insurance quotation request to Ellis Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Ellis Insurance Agency to confirm binding or altering coverage.

info@ellisinsurance.com

www.ellisinsurance.com

Driver Name	Date of Birth	License Number	License State:
Driver Name	Date of Birth	License Number	License State:
Driver Name	Date of Birth	License Number	License State:

Vehicle 1	Vehicle 2	Vechicle 3	Vehicle 4
Year/Make/Model	Year/Make/Model	Year/Make/Model	Year/Make/Model
Plate Number or VIN	Plate Number or VIN	Plate Number or VIN	Plate Number or VIN
Registration State:	Registration State:	Registration State:	Registration State:
Usage Radius	Usage Radius	Usage Radius	Usage Radius
Usage Description*	Usage Description*	Usage Description*	Usage Description*
Include collision and comprehensive coverage? Yes No	Include collision and comprehensive coverage? Yes No	Include collision and comprehensive coverage? Yes No	Include collision and comprehensive coverage? Yes No
Please select a liability coverage limit

Location 1	Location 2	Location 3
Street	Street	Street
City	City	City
Postal Code	Postal Code	Postal Code
Do you own or lease this location? Yes No	Do you own or lease this location? Yes No	Do you own or lease this location? Yes No
If you OWN the building, how much do you currently have it insured for? (if this is a new purchase then please enter 0)	If you OWN the building, how much do you currently have it insured for? (if this is a new purchase then please enter 0)	If you OWN the building, how much do you currently have it insured for? (if this is a new purchase then please enter 0)
If you LEASE the building, what is the value of your tenant improvements?	If you LEASE the building, what is the value of your tenant improvements?	If you LEASE the building, what is the value of your tenant improvements?
Please list other occupants in the building (if any)	Please list other occupants in the building (if any)	Please list other occupants in the building (if any)
What is the total value of your business personal property at this location? (furniture, fixtures, equipment, machinery, stock, etc)	What is the total value of your business personal property at this location? (furniture, fixtures, equipment, machinery, stock, etc)	What is the total value of your business personal property at this location? (furniture, fixtures, equipment, machinery, stock, etc)
Square footage of this space/building	Square footage of this space/building	Square footage of this space/building
Please select building construction material	Please select building construction material	Please select building construction material
Year of construction	Year of construction	Year of construction
If the building is over 25 years old, please describe any renovations	If the building is over 25 years old, please describe any renovations	If the building is over 25 years old, please describe any renovations
Any losses at this location in the last 5 years? Yes No	Any losses at this location in the last 5 years? Yes No	Any losses at this location in the last 5 years? Yes No
If yes, please describe (include date of loss and total amount paid)	If yes, please describe (include date of loss and total amount paid)	If yes, please describe (include date of loss and total amount paid)
Does the building have an alarm? Yes No	Does the building have an alarm? Yes No	Does the building have an alarm? Yes No
Is the building sprinklered? Yes No	Is the building sprinklered? Yes No	Is the building sprinklered? Yes No

Class Code (if known)	Description of Employees	# of employees	Annual payroll amount

Class Code (if known)	Description of officer's role	# of officers	Annual payroll amount