Commercial Insurance Quote Request Thank you for the opportunity to earn your business! We encourage you to watch the video below for more information on our commercial insurance discovery and quoting process! "*" indicates required fields Step 1 of 10 10% General Business InformationBusiness Legal Name*DBA (if applicable)Organization Type*Please select an option from the dropdownIndividual / Sole ProprietorLimited Liability Corp (LLC)Limited Liability Partnership (LLP)Incorporated (Corp)OtherContact Person's Name* First Last Contact Phone Number*Contact Email* Contact Person's Job Title*Business Website Address FEIN*DO NOT enter SSN. If no FEIN, enter 123456789.Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical address:* Same Different Business Physical Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you ever worked with a broker before:* Yes No Why are you shopping for insurance?*Please check all the apply New Venture Existing business with NO current coverage Price Bad Claims Experience Poor Customer Service Experience No local representation How did you first hear about us?* I am current customer Family/Friend Referral Channel Partner Referral (Mortgage Broker, Realtor, Other Insurance agent) Google Search Social Media Post (Facebook, Instagram, Twitter) Local Event Other What is your target price for the policies you are interested in quoting?*Please provide a realistic expectation of pricing so we know if we are able to meet them.Who referred you so we can send them a thank you:*What coverage is your business interested in?* General Liability Commercial Property Commercial Auto Cyber Liability Worker's Comp Professional Liability / Errors & Omission (E&O) Excess Liability / Umbrella Inland Marine (Builder's Risk / Contractor's Equipment / Installation Floater / Cargo) Garage Liability / Garage Keepers Check all that applyDoes the business perform any work as a contractor?*If your business is in the construction industry (ie Remodeling, carpentry, painting, drywall, electrical, plumbing, HVAC, etc), please check 'Yes' Yes No Do you have any contract requirements that need to be met with these policies (i.e. certain coverages or limits of liability)?*If yes, you will be given the opportunity to upload a copy of the contract requirement later in the application process. Yes No Contractor QuestionsContractor Type*Please select the contractor type that best fits your business. On the next page, you can describe in more detail.Please select an option from the dropdownCabinet / Countertop InstallCarpentry (Patios, decks, finishing installCommercial RemodelingConcrete / Flat work ONLYConcrete / FoundationDrywall Install, Tape & FloatElectricalExterior Painting (including interior painting)Interior Painting ONLYInsulation InstallationFloor Covering InstallFramingGeneral Contractor (100% subcontract work)HVACPlumbingResidential RemodelingRemediation / Restoration ContractorRoofingSolar Energy ContractorOTHERDo you preform any Tract Home work?*Work in any subdivision for a home builder with more than 20 homes? Yes No Do you have an active contractor's license?* Yes No Type of license:*License Number:*Commercial Work %*Please enter a number less than or equal to 100.Residential Work %*Please enter a number less than or equal to 100.New Construction %*Please enter a number less than or equal to 100.Remodel %*Please enter a number less than or equal to 100.Any work above 15ft or below 1ft surface?* Yes - Work above 15ft Yes - Work below 1ft underground No How often do you use a written contract with your customers?* Always Sometimes Never Additional Business InformationDescription of business operations:*Please provide a brief description of your business operation to help us understand all of your operations.Year Business Started*Please select an option from the dropdown20252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000prior to 2000Years of Industry Experience*Number of Owners*Please select an option from the dropdown1 Owner2 Owners / Partners3+ Owners / PartnersNumber of staffed locations:*Please select an option from the dropdownOnly oneMultiple locations but only in TexasMultiple locations in multiple statesOccupied Sq ft:*This is the occupied square footage for your business. If you have an office in your home, please list the size of the space for your home office.Number of Employees*Please indicate the number of W2 and uninsured independent contractors your business has.Occupied Sq ft:*This is the occupied square footage for your business. If you have an office in your home, please list the size of the space for your home office.Estimated Annual Gross Sales/Revenue*PLEASE NOTE: This should be your estimated gross sales or revenue for the upcoming 12 month period BEFORE any anticipated expenses, including, but not limited to: payroll, subcontract cost, materials, labor, taxes, etc.Estimated Annual Payroll*PLEASE NOTE: This should be the estimated payroll amount for W2 employees not including owners. 1099 independent contractors that you DO NOT require to have their own insurance or have a subcontractor agreement with should also be included in this number.What is the average cost of a project?*PLEASE NOTE: We are looking for the average total cost you charge a customer for a project you are working on.How many projects do you expect to complete in the next 12 months?*Include owners/officers in WC coverage?* Yes No List all NAICS/SIC codes for any type of work your employees do for youIf you don't know the NAICS/SIC codes, please describe as best you can the type of work your employees do you. Please also breakdown the percentage of your payroll for each class/code.Class Code (or Type of Work)Percentage of Payroll Add RemoveAre subcontractors used?* Yes No Subcontractor QuestionsDoes your subcontractor agreement include a hold harmless clause?* Yes No Do you require subcontractors to maintain General Liability Insurance matching your limits of liability?* Yes No Do you generally use the same subcontractors?* Yes No Estimated annual cost of INSURED subcontractors (incl. materials & labor)*Give a brief description of the work typically subbed out:* Property InformationIs this for a purchase?* Yes No Estimated Closing Date:* MM slash DD slash YYYY Purchase Price:% of building that is VACANT*% of building occupied by YOU (owner)*Year the building was built:*Total Building Sq Ft:*Is there a sign not attached to the building:* Yes No Replacement Cost of Sign: Type of Property*Please select an option from the dropdownResidential/HabitationalShopping CenterOffice BuildingOther# of Stories*Year of last major ELECTRICAL update to the building*Type of ELECTRICAL*Please select an option from the dropdownCircuit BreakersFuse BoxKnob & TubeUnknownYear of last major PLUMBING update to the building*Type of PLUMBING*Please select an option from the dropdownPVC/PEXCopperGalvanizedLeadUnknownYear of last major HVAC update to the building*Type of HVAC*Please select an option from the dropdownCentral AC & Gas HeatingCentral AC & Electrical HeatingWindow Unit - Cooling & HeatingWindow Unit - Cooling OnlyWall FurnaceOtherYear of last major ROOFING update to the building*Type of ROOFING*Please select an option from the dropdownComp ShinglesFlat - Built up SmoothFlat - Built up Tar & GravelMetal RoofOther / Not SureType of Alarm* None Local Centrally Monitored % of Building Sprinklered*Mechanical Updates Affirmation* I confirm that the property we are looking to insure does not contain any undesirable electrical elements (including but not limited to Federal Pacific (FPE) Stab-lock panel which has been found to be a fire hazard, fuse, knob and tube or aluminum wiring), and that plumbing and electrical elements are up to building code. I understand that a physical property inspection will be completed. If any undesirable elements are found to be present on the property, it will require remediation or coverage for the property may be set up to cancel. Tenant InformationWould you like to upload a copy of your rent rolls or manually enter the information on this application for each tenant?* Upload rent rolls Manually enter tenant information List of Tenants Suite Number Occupancy Tenant Name Square Footage Certificate of Insurance kept on file? Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Auto Liability SectionDo you have a DOT# / MC# or plan to get one in the next 6 months?* Yes No DOT #*If unavailable or not applicable, enter: "N/A"MC #*If unavailable or not applicable, enter: "N/A"What is the average driving radius for your business?*Please enter the average driving distance from your garaging address for the owned vehicles.Average number of jobsites visited daily*Please enter the average number of jobsites visited by your vehicles on a daily basis.Are any vehicles used in the business leased or rented on a long-term basis?* Yes No Please list the type of cargo being carried and percentage:*Example: "Raw Construction Materials / 30%" Use the "+" to add more lines as needed. Add RemoveAuto Liability Limit:*Filings Required* No Yes Hired/Non-owned Auto Required* Do Not Include Include Uninsured/Under-insured Motorist Coverage* Do Not Include Include Personal Injury Protection* Do Not Include Include Roadside Assistance* Do Not Include Include Current GL/BOP policy in force:* Yes No Interested in Telematics Discount* Yes No Cargo Coverage Requested* Do Not Include Include Limit Requested*Trailer Interchange Required* Do Not Include Include # of Trailers*Any additional coverage notes, requests, requirementsHow would you like to provide the driver list?* Enter drivers now Email list of drivers to you How would you like to provide the vehicle list?* Enter vehicles now Email list of vehicles to you Drivers InformationYou can add multiple drivers by clicking on "Add Entry" Driver Name Date of Birth Relation to Insured Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Vehicle InformationYou can add multiple vehicles by clicking on "Add Entry" Year Make Model VIN Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Current InsuranceHave you had a commercial auto policy in force without a lapse in coverage for at least the last 12 months?*Proof of your prior insurance will be required in order to maintain the discount. If proof of prior insurance cannot be provided, please select no. Yes No Have you had any claims or judgments filed against you in the last 5 years?* Yes No Prior Claims History Date of Loss Type of Loss Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Current Insurance Company:*Expiration Date:*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Expiring Premium:*Loss Run Reports*Do you agree to help us obtain a copy of your current loss run history report showing any losses/claims for the last 5 years? Yes No File uploadPlease use this opportunity to upload any contract requirements that you need met with these policies, loss runs (claims experience), current policy information, rent rolls, or current policy copies so that we are quoting appropriately. Drop files here or Select files Max. file size: 5 MB. Consent* I consent & agree to the following:The application information is true and correct to the best of my knowledge. By submitting this request you are authorizing My Insurance Group, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit, and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. My Insurance Group is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHA
