EQUITY INSURANCE AGENCY

CALL NOW for a FREE estimate on Home, Auto, Life, Business or Commercial Insurance!

630-627-7764

    HOME  |  About EIA  |  Services  |  Agent Referral  |  Contact EIA  |  Links


Commercial Insurance Request

* Required Fields

Name of Company:*
Address:*
City:*
State:* Zip:*
Type of Business*:
Contact Person:*
Bus. Tel:*
E-Mail:*
Insurance Information
Current carrier:
 Current premium:
$
Expiration date:*
 Years with carrier:
Please describe any additional coverage:
Please describe any losses last 3 years:
Year built:
 No. of floors:
 Total sq. ft.:
Type of building:

Office Strip Mall Other, explain
Type of construction:

Brick Frame Fire resistive (concrete floors & ceilings)
Basement: Yes No
Gross sales:
 Gross payroll:
Years in business:
 Years at location:
Types of Coverage Requested
Building:
$		 Deductible:
$
Business personal property:
$		 Business interruption:
$
Loss of rents:
$		 Liability limits:
$
Workmens Compensation Coverage
Number of employees:
 Total payroll for WC:
$
Federal Tax ID #:
 Class Code:
Any losses for this coverage, explain:
Commercial Auto Coverage
(We will call you to obtain vehicle and driver information.)
Limits of liability:
 Bodily injury:
$
Property damage:
$		 Comp deductible:
$
Collision deductible:
$
Number of vehicles:
Number of drivers:
Please describe any additional coverage:
Any losses for this coverage, explain:
Special Needs (check all that apply)

Professional Liability Bonds Special Events Liquor Liability Umbrella
Additional comments that may effect outcome of request(s):
   
If you would like to talk to a representative regarding any questions on this questionnaire, or an insurance request for something other then you see on our Web site, call our toll-free direct line at 877-627-7808 and we can take your insurance information directly over the phone.

Equity Insurance Agency works directly with independent insurance carriers to get you the best rates with "A"-rated companies with excellent claims and customer service.

© Copyright 2002 Equity Insurance Agency, Inc.