| BUSINESS INSURANCE QUOTE FORM |
| The Quote Form is our preliminary process of obtaining the necessary underwriting information. Be as thorough as possible. The current policy and claim history will also be required as part of the underwriting process. |
| First Name
Required
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| Last Name
Required
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| Contact Primary Phone Number
Required
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| E-Mail Address
Required
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| Business Legal Name
Required
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| Doing Business As Name or Type "NA"
Required
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| Number of Years in this Business?
Required
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| What type of Insurance do you want us to quote?
Optional
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| Mailing Address
Required
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| City
Required
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| State
Required
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| ZIP / Postal Code
Required
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| Business Type
Required
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| Describe your Business Operation: Salon, Barber Shop, School, etc
Required
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| Location Address
Required
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| City, State & Zip
Required
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| Current Estimated Gross Annual Sales or Receipts
Required
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| Number of Owners or Officers
Required
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| Number of Employees (excluding Owners and Officers)
Required
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| Annual Employee Payroll (Excluding Owners or Officers)
Required
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| Are Subcontractors Used?
Required
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| If Subcontractors are used, do you veritify that they have insurance?
Required
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| Number of Non Employees 1099s
Required
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| Annual Cost of Non Employees 1099s or type "NA"
Required
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| Annual Cost of Subcontractors or Type "NA"
Required
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| BUILDING & CONTENTS INFORMATION |
| Do you own the Building?
Required
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| Operating in:
Optional
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| How much Contents Coverage should we quote or type "None"
Required
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| Construction Type
Required
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| Total Building Square Footage?
Required
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| Your Occupied Square Footage
Required
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| Year the Building was Built (est)
Required
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| Age of the Roof
Required
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| Is there a sprinkler system in building?
Required
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| How many Beauticians or Barbers "Full Time"
Required
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| How many Beauticians or Barbers "Part Time"
Required
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| How many Beauty or Barber Chairs?
Required
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| How many Manicurists "Type None" if not applicable
Required
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| How many Tanning Beds or Booths "Type None" if not applicable
Required
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| How many Beauty School Teachers - type "NA" if not applicable
Required
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| CURRENT INSURANCE INFORMATION |
| Do you currently have Business Insurance?
Required
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| If yes, please provide name of current Insurance carrier. If no insurance, type "NA."
Required
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| Has there been a lapse in coverage in the last 3 years?
Required
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| Number of Additional Insureds Needed, if applicable or type "NA"
Required
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| Has your business had any claims in the past 3 years?
Required
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| Is there anything else that you would like for us to know concerning your quote request?
Optional
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| How did you hear about us? Please let us know
Required
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| SIGNATURE REQUIRED |
| I have provided all of the above information for insurance purposes and I state all information is true to the best of my knowledge. I also understand that I am to discuss with the agent at D. Ward Insurance my desired limits and coverage. |
| By typing my name warrants my signature.
Required
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| ADDITIONAL INFORMATION NEEDED |
| Please note - if the Business is insured, a copy of the policy and claim history will be required. They can be obtained from your current agent by requesting the documents to be sent electronically to you. |
| Thank you for time and we will be in touch with you today unless this is after hours or on the weekend - Debbie Ward and Valerie Moore |
| ENTER VALIDATION CODE |
| For Security of your personal information, enter code and press submit |
Submission Validation Required |
Enter the Validation Code from above.
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