Thank you for taking the time to complete this simple to use Commercial Insurance quote form. The following questions will give us a general understanding of your business and assist us in putting together a compressive insurance package for you to consider. While some policies are easier to write, many involve a more lengthy application process. Please complete as much of the form below as possible. Take a minute to add your comments as the more information we have the better. If you currently have an insurance policy with someone else please complete the form and fax us a copy of your current policy (413-527-5970). This will give us a chance to review your policy (with no obligation) and ensure we are giving you the most comprehensive quote possible.


Please fill in and the following information about your business.

Name (First, Middle, Last):
Business Name:
Business Address:
City: Zip: State: MA
Email Address:
Business Website (put N/A if none):
Phone: Work#: Ext: Fax #: Cell #:


Business Underwriting Information
Type of Operation:
Describe Operations below:
Social Security or Fed. ID#:
Limit of Liability Coverage Requested?  
Are You Currently Insured? Yes No
Carrier's Name and Renewal Date:
Prior Claims? Yes No
Describe Prior Claim:
Past Coverage?? Yes No
Have you had coverage canceled
or non-renewed in the past 3 years?
Yes No
Years in Business:
Years of Experience in Field:
Percentage of Work Residential:
Percentage of Work Commercial:
Number of Active Owners:
Number of Employees?
Annual Employee Payroll: $
Annual Gross Sales: $
Do You Subcontract Work? Yes No
If yes, what % of your work is subbed,
and kind of work subbed?
Please Contact Me Via:

Additional Comments / Remarks:

   

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6 Campus Lane, Easthampton, MA 01027 • 413 527-3000 • fax 527-5970 ••• 63 Main Street, Florence, MA 01062 • 413 584-1970 • fax. 586-9069
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