<%language="vbscript"%> Quick Quote
 


Online Quote Form



Trust Name:
First Name
Last Name
Salutation Mr. Mrs. Ms. Miss Dr.
E-mail Address
Telephone Number
Fax Number
Business Street Address
Business City
Business State
Business ZIP Code
 

Name of Business(es) 

Type of Business
Sole Proprietor Limited Liability Company (LLC)
Partnership Professional Service Liability Company (PSLC)
Corporation Registered Limited Liability Partnership (RLLP)
Political Subdivision Other -specify

Anticipated Effective Date of Insurance    Year    (required)
(must be current or future date)

Describe your business operations, including products or services sold

List your estimated annual payroll by type of work or duties
Classification Payroll (no commas please) Number of Employees
Clerks/Bookkeepers
Outside Sales/Messengers
Corporate Officers

List and describe other classifications that may apply to your business (include payroll and employee count)

 
Note: Up to two corporate officers who collectively own 100% of the corporation's stock have the option to be excluded from coverage.

Should any officers be excluded? Yes  No
If Yes, list officers to be excluded:
First Exclusion: First Name Last Name
Second Exclusion: First Name Last Name
Note for Sole Proprietors and Co-Partners: If you are self-employed or a partner (as defined under Section 10 of the Partnership Law), you may be covered but the premium would be based on a remuneration of at least $22,100 and not more than $66,300 annually through September 30, 2000.
Does this apply to you?  Yes  No
If Yes, please complete the following:
Sole Proprietor: First Name Last Name
1st Partner: First Name Last Name
2nd Partner: First Name Last Name
Additional Partners:

Would you like a representative to contact you? Yes  No