Business/Commercial Quote

Last Name (Contact)
First Name
M. I.
Company Name
Physical Address
City
State
Zip
County
Mailing Address (if different)
City
State
Zip
County
Email
Web site
Home Phone
Cell Phone
Work Phone
Type of Business
Contractor? (Example: painting, carpentry, plumbing)
Office? (example: law, dental, doctor)
Restaurant?		Please Select Yes No
If ‘Yes’ to Restaurant, how many days per week?”
Is there a Dance Floor?		Please Select Yes No
Live Band?		Please Select Yes No
Cover Charge?		Please Select Yes No
Retail?		Please Select Yes No
Manufacturer?		Please Select Yes No
Service?		Please Select Yes No
Other than above (What Type?)
Description of Services
New Business?		Please Select Yes No
Prior Experience in this type of business?		Please Select Yes No
If no, how many years in business?
Number of Employees
Total Payroll
Type of Employees
Total Sales/Receipts
Subcontractors Used?		Please Select Yes No
If yes, what percentage of your sales or receipts do they represent?
What type of work is subcontracted out?
Certificate of Insurance obtained showing proof of coverage?		Please Select Yes No
Type of Building Construction from which business operates?		Please Select Brick Frame Non-Combustible Fire Resistive
Year Built?
Distance to Fire Hydrant in Feet
Distance to Fire Department in Miles
Value of Contractor Tools and/or other Mobile Equipment?
Value of Office Equipment, Inventory and/or other Assets?
Liability Limits?		Please Select 300,000/600,000 500,000/1M 1M/2M
Add Business Umbrella/Business Catastrophe Liability coverage?		Please Select 1M 2M 3M 4M 5M Not at this time
Claims/losses in the last 5 years		Please Select None 1 2 3 4 More
Please provide date, amount and brief description of each incident
Present Insurance Company
Renew Date

Bradley Agency Disclaimer for On-Line Quote By choosing to use this web site (bradleyagency.com) to request an insurance quote, you agree to the following terms and conditions. The materials and information contained in this web site are provided “as is” and without warranty of any kind, either expressed or implied.  The Bradley Agency assumes no liability whatsoever for damages of any kind incurred as a result of your request for a quote or use of this website. Your request for an insurance quote will not bring into effect any insurance coverage.  Insurance coverage may only be effected when your application for insurance is accepted by the Bradley Agency and approved by the carrier as evidenced by the inception date as indicated on a policy. Your entire quote, including the estimated premium and the prospective terms of coverage are tentative and are subject to change without notice based on any and all underwriting criteria, rating dates, manuals, plans and classifications used by Bradley Agency. In the event that there is a difference in the information, rates, premiums or terms contained in a quote and any insurance policy issued to you by the Bradley Agency, the policy governs.