JGI - Commercial

Commercial Insurance Request

Type of Insurance

example: General Liability, Contractors Insurance, Property/Building and/or Content, Commercial Auto, Workers Comp, Other (if other, please specify)

General Information

First Name

Last Name

Doing Business As

Email

Phone Number

Address

City

State

Zip

Business Information

# of Full-Time Employees

# of Part-Time Employees

How may years in business?

How many business locations?

Current Coverage

Carrier Name

Policy Number

Current Type of Coverage

example: General Liability, Contractors Insurance, Property/Building and/or Content, Commercial Auto, Workers Comp, Other (if other, please specify)

Property/Premises Information

Address

City

State

Zip

Year Built

% Occupied

Stories

Sq. Footage

Building Value

Content

Sprinklers?

Burlar Alarm?

Owner Occupied?

Insurance Information

Business Personal Property Amount

Annual Gross Sales (Before Taxes)

Payroll

Liablity Limites Requested

Additional Information (Claims)

Please Note that coverage cannot be bound via quote request form