Business Name:
Premises Address:
City:
State:
Zip Code:
Contact Name:
Phone #:
Ext #:
Fax:
Years in Business:
Email Address:
(Required)
Description of Operations or SIC code:
Current Insurance Company:
Policy Expiration Date:
(mm/dd/yyyy)
Annual Sales: $
Payroll: $
Business Income: $
Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years:
Select One
Yes
NO
Description of losses or loss runs:
Coverage Amounts Desired:
Liability Limit Desired:
Select One
$500,000
$600,000
$1 million
$1.5 million
$2 million
Deductible Desired:
Select One
$None
$1,000
$2,500
$5,000
Or choose other liability limit amount: $
Umbrella Amount Desired:
Select One
None
$1 million
$2 million
$3 million
$4 million
$5 million
Connecticut Property Info:
Building 1
Building Value: $
Contents Value: $
Total Building Area:
Year Built:
Construction Type:
Select One
Wood Frame
Steel Reinforced
Mill
Concrete Block
Concrete Tilt Up
Sprinklers:
Select One
Yes
NO
Central Alarm:
Select One
Yes
NO
List Neighboring Businesses:
To the right:
Distance:
To the left:
Distance:
To the rear:
Distance:
Building 2
Building Value: $
Contents Value: $
Total Building Area:
Year Built:
Construction Type:
Select One
Wood Frame
Steel Reinforced
Mill
Concrete Block
Concrete Tilt Up
Sprinklers:
Select One
Yes
NO
Central Alarm:
Select One
Yes
NO
List Neighboring Businesses:
To the right:
Distance:
To the left:
Distance:
To the rear:
Distance:
Additional Information or Comments
Click on the "Submit Quote Information" button below to send your
Connecticut Commercial Property Insurance quote request.