Business Insurance Quote Form
Business Name:
Legal Entity:
- Select -
Sole Proprietorship
Partnership
LLC
S Corporation
C Corporation
Other
Years in Business:
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1
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50+
Annual Revenue:
- Select -
Under $100,000
$100,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
Over $10,000,000
Partners / Owners:
- Select -
1
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50+
Full-Time Employees:
- Select -
0
1
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50+
Part-Time Employees:
- Select -
0
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50+
Sub-Contractors:
- Select -
0
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31
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33
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35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50+
Is this a one-time or seasonal business or event?:
Yes
No
SIC code [
list
]:
Number of subsidiary businesses:
- Select -
0
1
2
3
4
5
6
7
8
9
10+
Property / Casualty Insurance
Employee Benefits
General Liability
Group Health Insurance
Commercial Auto
Group Life Insurance
Commercial Property
Group Disability Insurance
Professional Liability (E&O)
401K / Retirement Plans
Directors and Officers Liability
Supplemental Plans / AFLAC
Business Owners Package Policy (BOP)
Key Man Life Insurance
Workers Compensation
Key Man Disability Insurance
Commercial Crime
Deferred Compensation
Business Contact
First Name:
Last Name:
Street Address:
City:
State:
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Email:
Day Phone:
Cell Phone:
The following two fields are not required:
Referred By:
Branch:
Lead solicitation disclosure:
An Insurance Services Agent may contact the individual who fills out this form.
All Insurance Products:
Not a deposit or obligation of
any bank or credit union
Not FDIC Insured
Not Insured by any Federal
Government Agency
Not Guaranteed by any bank
or credit union
Copyright
2010
Somerset Financial Services Group
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