Commercial Quote Entry for Agents - Advance Insurance & Benefits

Commercial Quote Request Form for Agents

This form asks the MINIMUM REQUIRED information needed to start a new commercial quote. The Commercial Marketing Team cannot start quoting without this information.

"*" indicates required fields

Step 1 of 7 - General Info

Hello! What would you like a quote for?*

General Liability monoline

Commercial Property monoline

BOP (GL+Property)

Commercial Auto

Workers Comp

Umbrella*

Tools & Mobile Equipment*

Contractors Pollution Liability*

Cyber Liability*

Professional Liability / E&O*

Check all that apply. You can tell us if there is something else you need a quote for in just a moment. *Additional Info or Supplemental Application is likely required. Contractors will also require additional info and/or supplemental applications.

Business Legal Name or DBA if applicable for Sole Proprietors*

Include your LLC/Corp name and your DBA, e.g. ACME Construction LLC DBA Nevada Contracting

Legal Entity Type*

NAICS Code

This is helpful but not required, use the link below to search the NAICS codes

NAICS Search Page

Contact Name*

Email*

Phone*

Website

Would you like to obtain the Owner Financial Score if available?*

Yes

Many companies offer premium credit when they can establish a Financial Score for the Owner. You'll need the owner's Name, DOB, Home Address and sometimes their SSN.

Owner Financial Score*

Owner Name

Home Address

DOB

SSN

Tax ID (EIN for LLC/Corps or SSN for Sole Proprietors)*

Enter as XX-XXXXX for EIN or XXX-XX-XXXX for SSN

What year was the business established?*

How many years experience does the Owner have?*

Insured Location Address*

Street Address Address Line 2 City State ZIP Code

Is there a different Mailing Address?*

Yes

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are there multiple physical locations?*

Yes

Is this a home based business?*

Yes

Does the applicant own any other businesses?*

Yes

What other businesses does the applicant own?*

Description of Business Operations*

Please provide a short description of the Business Operation (at least 5-10 words preferred)

Estimated Gross Annual Sales*

Gross Annual Payroll*

Total Number of Employees*

Are subcontractors used?*

Yes

Subcontractor Cost*

Work Subbed Out

Annual Cost

Is the applicant a subsidiary of another entity or do they have any subsidiaries?*

Yes

Payroll Break Down - Be Accurate*

Job/Class Code

Annual Payroll

# of FT Employees

# of PT Employees

Example: 8810 Clerical | $50,000 | 2 (If you know the WC Class Code you can use it, otherwise just enter a description)

Do you know what your current Experience Modifier (XMod) is?*

Yes

Not Sure

What is your current Experience Modifier (XMod)?*

Enter the XMod only as a number, e.g. 0.95 or 1.20

Any work performed underground or above 15 feet?*

Yes

Is a written safety program in place?*

Yes

Is there any volunteer or donated labor?*

Yes

Any seasonal employees?*

Yes

Do employees travel out of state?*

Yes

Do you lease employees to or from another employer?*

Yes

Has the business been performing work without coverage?*

Yes

Please explain why work has been performed without coverage and for how long*

What Commercial Property coverage options are needed?*

Building

Business Personal Property

Tenant's Improvements & Betterments

Equipment Breakdown

Business Income / Extra Expense*

Bailee's Coverage

*BI/EE will be quoted as 12 months Actual Loss Sustained when available, otherwise a limit will need to be decided by the insured.

Building Coverage*

Building Limit

Deductible

Most carriers will verify Building limits with their own Replacement Cost calculations

Business Personal Property Coverage*

BPP Limit

Deductible

TI&B Coverage*

Limit

Deductible

Building Square Footage*

Building Year Built*

Building Updates*

Roofing Year

Plumbing Year

Electrical Year

HVAC Year

Number of Stories*

Construction Type*

Occupancy (in Sq Ft)*

SF Occupied by Insured

SF Occupied by Tenants

SF Vacant

Square Footages must equal total Building SF

What Protections are in place?*

Fire Sprinklers

Automatic Fire Supression (ANSUL system)

Surveillance Cameras

Central Monitored Alarm System

Local Alarm System (not monitored)

Controlled Access

What Auto Liability Limit do you require?*

MedPay Limit*

UM/UIM BI Limit*

Drivers*

First Name

Last Name

DOB

DL#

DL State

Married/Single

CDL Y/N

If you have more than 4 drivers to list, please upload a spreadsheet at the end of this form.

Vehicles*

Year

Make/Model

VIN

Max Radius

If you have more than 4 vehicles to list, please upload a spreadsheet at the end of this form.

Are any of these options required?*

Symbol 1 - Any Auto Liability

Hired Auto Liability / Physical Damage

Non-Owned Auto Liability

Auto Liability will be quoted at Symbol 7 - Scheduled Autos Only, or its equivalent, unless otherwise requested by the agent/insured.

Are all vehicles owned by the Insured listed?*

Yes

Symbol 1 requires that All Owned Vehicles be listed on the policy

What is the estimated Annual Hired Auto cost?*

Are you in the automotive sales, service or repair business?*

Yes

Garagekeepers coverage*

Max per auto limit

Max limit

Deductible

Garagekeepers is a Bailee's coverage that covers damage to your customer's autos while in your Care, Custody & Control. Coverage will be quoted on Direct Primary Basis unless only the Legal Liability option is available.

Does the insured have a DOT#?*

Yes

DOT Number*

What state/federal filings are needed?*

Answer "none" or "not sure" if none apply or you aren't sure

Does the insured have current coverage for the lines being requested?*

Yes

No current coverage

They have current coverage but not for the lines requested

Current coverage has cancelled / lapsed

Current Coverage*

Line

Carrier

ExDate

Premium

Does the insured have any losses or claims in the past 3 years?*

Yes

Most carriers will request loss runs to verify loss history

Loss History*

Loss Date

Type

Amount Paid

This is not required, but if readily available, please upload your most current Certificate or insurance policy coverage declarations pages in PDF format so we can see the exact coverage limits you'd like us to compare. These can be easily downloaded from your online profile with your current provider (if you have a login), or from your current agent.

Drop files here or

Max. file size: 39 MB.

If you have any other questions, comments or requests, please leave them here

Agent*

Agent Email*