COMMERCIAL QUOTE - WISCONSIN RESIDENTS ONLY
General Information
Contact Name
Contact Email
Name of Business
Nature of Business
Address
City, State ZIP
Business Phone
Cell Phone
Fax
Current Insurance Company
Company Name (not agency)
Policy Expiration Date
Current Insurance Coverages
Current Coverages	Bond			Commercial Auto
(Check What You Currently Carry)	Commercial Liability			Worker's Compensation
	Commercial Property			Commercial Umbrella
	Directors and Officers Liability
	Group Health			Group Life
	Professional Liability				Disability
	Other (please explain)
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)			yrs.
How many locations?
Please give a brief description
of your business and clientele.
Property & Premises Information
Address
Occupancy Status	Owner		Tenant
Year Built
% Occupied			%
Sprinklers	Yes		No
Construction Type
Stories
Basement
Sq. Footage			Sq. Ft
Security System	Yes		No
Building Value	$
Contents Value	$
Other Property (specify)
Insurance Information
Annual Gross Sales (before taxes)	$
Number of Employees
Annualized Payroll	$
Cost of any Subcontracted Work	$
Limits Requested	$300,000		$500,000		$1,000,000
	$2,000,000
Describe any claims you've had
in the past 5 years:
Additional Comments: