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Business Insurance Quote Form
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Coverage
Selection
Which type of insurance are you looking for?
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General Liability
Business Owners Policy
Commercial Auto
Workers’ Compensation
Commercial Property
Group Health
Other
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Business
Information
Business Name
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Contact Person
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Email Address
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Phone Number
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Business Address
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City
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State
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ZIP Code
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Years In Business
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Business Type
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Select Business Type
LLC
Corporation
Sole Proprietor
Partnership
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Coverage-Specific
Questions
General Liability
Industry
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Select Industry
Contractor
Restaurant
Retail
Office
Professional Services
Annual Revenue
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Number Of Employees
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Business Owners Policy
Industry
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Select Industry
Contractor
Restaurant
Retail
Office
Professional Services
Annual Revenue
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Number Of Employees
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Commercial Auto
Vehicle Count
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Select Vehicle Count
1
2
3-5
6+
Driver Count
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Select Driver Count
1
2
3-5
6+
Garage & Dealers Policy
Type Of Business
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Select Type Of Business
Auto Repair Shop
Dealership
Body Shop
Tire Shop
Tow Truck Service
Other
Years In Business
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Number Of Employees
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Annual Revenue
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Number Of Dealer-Owned Vehicles
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Select Vehicles
1-10
11-25
26-50
50+
Estimated Inventory Value
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Workers’ Compensation
Number Of Employees
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Estimated Annual Payroll
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Trucking
Truck Count
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Select Truck Count
1
2-5
6-10
10+
Operating Radius
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Select Radius
Local
Regional
Interstate
Professional Liability
Type Of Profession
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Annual Revenue
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Equipment Floater / Inland Marine
Type Of Business
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Select Type Of Business
General Contractor
Electrician
HVAC
Plumber
Landscaper
Other
Total Equipment Value
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Largest Individual Item Value
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Equipment Used Offsite?
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Select
Yes
No
Commercial Property
Property Address
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Building Value
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Contents Value
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Commercial Umbrella
Existing Policies
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General Liability
Commercial Auto
Workers’ Compensation
Employer's Liability
Property
Desired Umbrella Limit
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Select Limit
$1 Million
$2 Million
$5 Million
$10 Million+
Annual Revenue
*
Number Of Employees
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Current Carrier
Cyber Liability
Do You Store Customer Information?
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Select
Yes
No
Do You Accept Credit Cards?
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Select
Yes
No
Crime Liability
Number Of Employees
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Annual Revenue
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Do Employees Handle Money?
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Select
Yes
No
Do Employees Have Access To Bank Accounts?
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Select
Yes
No
Group Health
Industry / Type of Business
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Are You Currently Offering Group Health Insurance?
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Select
Yes
No
Desired Coverage Start Date
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Number of Employees Expected to Enroll
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Do You Want to Offer Dependent Coverage?
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Select
Yes
No
Employer Contribution Preference
*
Select
Employer pays a percentage of employee premium
Employer pays 100% of employee premium
Employer pays a fixed amount per employee
Employee pays 100% (no employer contribution)
Other
Additional Comments
Please do not include sensitive medical details, Social Security numbers, payment information, or confidential employee health information in this form.
Upload Employee Census File
If you do not have a census file ready, you may submit the form without uploading one, and an Eversafe Insurance Agency representative will follow up with you.
By providing my phone number, I agree that Eversafe Insurance Agency may contact me by phone call or text message regarding my quote request, policy service, or related insurance communications. Message and data rates may apply. Message frequency may vary. I may reply STOP to opt out or HELP for assistance. Consent is not required as a condition of purchasing insurance.
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I understand that submitting this form does not bind coverage, does not guarantee quote approval, and does not create an insurance policy. Coverage availability varies by carrier and state. Policy terms, conditions, exclusions, and limits apply.
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Other Insurance
Please Describe The Type Of Insurance You're Looking For
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Industry
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Annual Revenue
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Number Of Employees
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