Insurance Commercial Package Quote

INSURANCE COMMERCIAL PACKAGE QUOTE

Producer / Quoter

Producer Name:

Producer Contact:

Quote Number:    Date of Quote:    Expiration:

Insured / Applicant Information

Mailing Address:

FEIN / Tax ID:    State of Incorporation:    Years in Business:

Primary Contact Phone:    Email:    Primary Contact DOB:

Business Operations

NAICS / SIC Code:    Number of Employees:    Estimated Annual Payroll:

Locations / Premises

Policy Details & Period

Policy Form:    Policy Period From:    To:

Coverage Options & Limits

Property Coverage (Building & Contents)    Limit:    Deductible:    Annual Premium:

General Liability (Occurrence)    Each Occurrence:    Annual Premium:

Business Auto Liability    Limit:    Annual Premium:

Workers' Compensation (if applicable)    State:    Estimated Premium:

Crime / Fidelity    Limit:    Annual Premium:

Cyber Liability    Limit:    Annual Premium:

Exclusions / Restrictions

Standard exclusions applicable unless specifically endorsed: acts of war, intentional acts, wear and tear, pollution (unless included), professional liability (unless endorsed). Any additional exclusions proposed:

Loss History

Claims in past 5 years (number):    Total Incurred:

Underwriting Requirements & Conditions

This quote is provided subject to satisfactory completion of underwriting verification, receipt of all requested documentation, and any site inspection as required by the insurer. Specific conditions or requirements to bind coverage:

Required Documentation Checklist

Completed ACORD or application

Financial statements (last 2 years)

Lease agreement (if tenant)

Floor plans / property schedule

Loss runs (past 5 years)

Drivers list & MVRs (for autos)

Payroll reports / schedule of employees

Premium Computation

Gross Premium:    Taxes & Fees:    Total Annual Premium:

Payment Plan Options: Full Payment    Installment Plan    Estimated Monthly Installment:

Additional Interested Parties / Beneficiary Designation (if applicable)

Name of Additional Insured / Loss Payee / Beneficiary:

Interest / Relationship:    Percentage of Proceeds (if beneficiary):

Declarations & Certification

The undersigned represents that the information contained in this application and any attachments is true and complete to the best of their knowledge. This quote is an offer to provide terms for insurance coverage and is not a binder or policy. No coverage will be in effect until the insurer has accepted the application, any required premium or deposit has been paid, and a policy or binder has been issued. The insurer reserves the right to modify terms, conditions, limits, and premiums based upon results of underwriting verification including inspections and third-party reports.

The insured authorizes the producer and insurer to obtain and exchange underwriting information, loss history, claims data and other relevant records necessary to evaluate risk. Any misrepresentation, omission or concealment of material facts may render coverage void or voidable, and may be a basis for premium adjustment or declination of issuance.

This quote is valid only for the named insured and is contingent on continued accuracy of the representations on this form until policy inception. Acceptance of this quote requires execution by an authorized representative of the named insured and payment as described above.

Underwriting Notes / Broker Comments

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