If you do not want a quote on any of the below areas of coverage, you do not need to fill them out. All other areas, please complete fully. Thank you for choosing J.A.S. Insurance Services for a free quote.

 

Business Quote Form

Referred From:

Business Type:

Company Name:

Address:

City:  State:  ZIP:

Contact Person:

Phone:

E-Mail:

Website Address:

Years in Business:

Years Experience:

Effective Date:

Incorporation Status:




Describe applicant's business operations including type of products made & clients:

Annual Sales $  Building Value $

BPP Limit $   PP of Others $

Deductible $

Check one:
Replacement Cost/ACV
Full Replacement Cost

Liability limits (check one):


Hired & Non-Owned Vehicles?
If employees routinely use own/rent vehicles, provide driver info

Driver #1:  
Name:
DL#:
DOB:
Driver #2:  
Name:
DL#:
DOB:
Driver #3:  
Name:
DL#:
DOB:

Building Information

Construction:    Square Feet:

# of Stories:    Year Built:

Sprinklers?   Alarm?

Alarm Type:

Updates (required if building is over 30 years old):
Heat    Wiring    Plumbing    Roof

Does Insured own or operate any other business other than described premises?

Any exposing property within 60 feet of applicant's property?

Loss history for past 5 years including carrier:

Is insured open 24 hours?

% of sales from website

If lessor or commercial condo, list occupancies:

Describe applicant's business operations including actual duties, final product, and specific field or areas of business (research, mfg, construction):

Crime Prevention

How often are deposits made?

Maximum amount of cash on premises:

Is there exterior lighting in front/back?

Is there wire mesh or bars on doors/windows?

Additional Insured info:

Workers' Compensation

Federal Id #:       Limit:

Class Code:   Payrolls:

Class Code:   Payrolls:

Class Code:   Payrolls:

Class Code:   Payrolls:

Experience mod:     Choose One:     

Expiring Premium:

Loss history for past 5 years:

Officers excluded or included: (Provide names & payrolls)

Officer 1:  
Name:
Title:
% Ownership:
Payroll:
Status:
Officer 2:  
Name:
Title:
% Ownership:
Payroll:
Status:
Officer 3:  
Name:
Title:
% Ownership:
Payroll:
Status:

Does insured have safety program in place?

Commercial Auto

Liability Limit:    Comp:

Collision:   Towing:

Rental Reimbursement:

Number of Employees:

Driver information:  Name, Driver License Number and Date of birth for all drivers including family members: (Note:  There must be one driver for each car)

Driver #1:  
Name:
DL#:
DOB:
Driver #2:  
Name:
DL#:
DOB:
Driver #3:  
Name:
DL#:
DOB:

Vehicle information:

Vehicle 1:  
Make/Model:
 VIN:
Cost New: $
ZIP Code where Garaged:
GVW (trucks only):
Vehicle 2:  
Make/Model:
 VIN:
Cost New: $
ZIP Code where Garaged:
GVW (trucks only):
Vehicle 3:  
Make/Model:
 VIN:
Cost New: $
ZIP Code where Garaged:
GVW (trucks only):

Does insured have a formal safety program?

Does insured have a maintenance program in place?

Loss History for previous five years:

Note: There must be one driver per vehicle

Once you submit this form, a representative of J.A.S. Insurance Services will contact you by phone or by email within the next 48 hours.