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.