Commercial Lines Quote
Fields marked (
*
) are mandatory.
Please fill out the following information to obtain
an insurance quotation. If you have any questions please feel free to call.
Business Name
Contact Name
*
Street
City
State
Connecticut
Zip
Email
*
Telephone
*
Fax
Cell
Current Insurance Company
Current Policy Expiration Date
Business Type
Please select
Contractor
Retail
Wholesale
Service
Manufacturer
Garage
Other
Years in business
Business Description
Briefly list the claims your company has filed in the past 36 months. Include date of claim, description and
amount reserved and paid. We may need to verify this with subject to company issued loss runs.
Claims Information
Please indicate the lines of insurance you are interested in
General Liability
Business Personal Property
Commercial Auto
Workers Compensation
Equipment
Umbrella
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