Commercial Lines New Business Questionaire

(* Required Field)
Contact Name: *

Disclaimer: No insurance coverage or policy change will take effect until a Hoffman Group associate advises you by phone or through written communication that coverage has been placed. If you need immediate service, please call us at (800) 826-4006.
Business Name: *
Referred By:
Phone: *
Fax:
E-mail: *
Received any other quotations?
If so, from whom? Target Price?
Date Need Proposal
Location Address Any other locations?
Mailing Address (if different)
Entity If other, please specify Years in Business
Type of Operations
Specific Business Operations *
Current Insurance Company Losses in last 3 years

Property
Location 1
Building Limit
Contents Limit
Business Income Limit
Construction Type
Square Footage
Deductible
 
Location 2
Building Limit
Contents Limit
Business Income Limit
Construction Type
Square Footage
Deductible

General Liability

Limits $500,000 each occurrence
$1,000,000 each occurrence annual
$1,000,000 each occurrence
$2,000,000 each occurrence annual
Annual Sales
Annual Payroll
Number of Employees

Automobile Information:
Driver 1
Name
SS#
Vehicle 1
Make/Model
Year
Garaging Zip Code
Use
Deductibles
Cost New
Comp. Ded.
Collision Ded.
Driver 2
Name
SS#
Vehicle 1
Make/Model
Year
Garaging Zip Code
Use
Deductibles
Cost New
Comp. Ded.
Collision Ded.
Inland Marine
Contractor's Equipment Value Tools Value
Installation Floater Other Value
Computers
Hardware Value Software Value
Extra Expense Value Other Value
Umbrella
Limits
Disclaimer: No insurance coverage or policy change will take effect until a Hoffman Group associate advises you by phone or through written communication that coverage has been placed. If you need immediate service, please call us at (800) 826-4006.