Commercial Insurance Quote Application

Commercial Insurance Quote Application
Legal name of business: *
DBA:
Type of entity: *
Federal ID# *
Social Security # of Individual to be Insured: *
Contact First Name *
Contact Last Name *
Is Contact Name listed above same as Business Owner? *

Yes No
Phone Number *

- Area Code Phone Number
E-mail *
How did you hear about us? *
Which agent are you working with at WPi?

Address Information
Website:
Street Address
City
State
Zip Code
Do you own or lease this property?

Own Lease
Does the location address differ from the mailing address? *

Yes No

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

What date would you like your coverage to start?:

- Month - Day Year
What date did your business begin current ownership?

- Month - Day Year
How many years of experience do you have in the industry?
Detailed description of Business Operations:
Type(s) of insurance needed (may choose multiple):

General Liability Business Auto Commercial Property Workers Compensation Lessor's Risk Professional Liability Cyber Liability Employers Practices Liability

Rating Information
Annual Sales:
Annual Rents:
Annual Payroll (sum of all payroll):
Does the company have a restaurant and/or bar?

Yes No
Annual Food Sales:
Annual Liquor Sales:
Annual Gaming Revenue:
Number of Full-Time Employees
Number of Part-Time Employees

Amount of Coverage
Building Amount:
Loss of Business Income:
Please enter desired Loss of Business Income coverage amount:
Contents Amount:
Please enter desired Contents Amount:
Tenant Improvements:
Please enter desired Tenant Improvements amount:
Signs:
Please enter desired Signs coverage amount:
Liability:
Enter Liability Limit Desired:
Deductible
Please enter desired Deductible below:

Building Construction
Please select ALL that apply to the property:

Frame Sprinklers Joisted Masonry Fire Alarm Burglar Alarm
Square footage of the property:
Number of Stories
Year Built

Additional Underwriting Information
Current Insurance Company
Have you/your company had any bankruptcies?

Yes No
Any claims in the past 5 years?

Yes No
Please describe claims by date and nature of claim below:
Business Owners Legal Name: *

First Name Last Name

Business Owner's HOME address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Business Owner's Date of Birth: *

- Month - Day Year

Business Auto Questions
Do you have a General Liability Policy currently in place?

Yes No

Drivers Information - if you have more than a handful of drivers, please attach document with the following information for all drivers at end of this form OR send to service@wpinsure.com.

	Full Name	DOB	Drivers License Number and State	SSN	Marital Status
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Driver 6

Vehicle Information - if you have more than a handful of vehicles, please attach document with the following information for all vehicles at end of this form OR send to service@wpinsure.com.

	Year	Make	Model	VIN	Owned? (Y/N)
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6

Please Upload Declarations Pages of Your Current Policies:
Should be Empty:

Commercial Insurance Quote Application

Address Information

Rating Information

Amount of Coverage

Building Construction

Additional Underwriting Information

Business Auto Questions