Business Owners Quote Form – Ramsgate Insurance

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Do you have completed Acords (125, 126 & 140)? *

Please describe your client's business operations.

SIC/NAICS Codes are helpful.

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RATING STATE

Rating State

Policy/Form Type

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MGA PREFERRED AGENCY NETWORK INFORMATION

Are you a MGA Preferred Agency Network Member *

Would you like more information on the MGA Preferred Agency Network? *

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AGENCY/BROKERAGE LOCATION INFORMATION

Business Name *

Agent/Broker/Rep

Address Line 1 *

Agent/Broker/Rep

Address Line 2

Agent/Broker/Rep

City *

Agent/Broker/Rep

State Code *

Agent/Broker/Rep

Zip Code *

Agent/Broker/Rep

Business Phone *

Agent/Broker/Rep

Business Ext

Agent/Broker/Rep

Business Fax

Agent/Broker/Rep

Does the Agency/Brokerage have a website? *

Website URL *

Does the Agency/Brokerage have multiple locations? *

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AGENCY/BROKERAGE CONTACT INFORMATION

Primary Contact First Name *

Agent/Broker/Rep

Primary Contact Middle Name

Agent/Broker/Rep

Primary Contact Last Name *

Agent/Broker/Rep

Mobile Phone

Contact Email1 *

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YOUR CLIENT'S BUSINESS LOCATION INFORMATION

Business Name *

Include DBA, if applicable.

Address Line 1 *

Address Line 2

City *

State Code

Zip Code *

Business Phone *

Business Ext

Business Fax

Date Business Started *

MM/DD/YEAR

What is the legal structure of your customer's business? *

Clients Business Information

Federal Tax ID/SSN

Clients Business Information

Does your client's business have a website? *

Clients Business Information

Website URL *

Clients Business Information

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YOUR CLIENT'S BUSINESS OWNER/CONTACT INFORMATION

Primary Contact First Name *

Primary Contact Middle Name

Primary Contact Last Name *

Mobile Phone

Contact Email2 *

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GENERAL POLICY INFORMATION

Is your customer's business currently insured? *

Policy Status *

Start-Up or Expired?

Requested Effective Date of Policy *

Current insurance carrier. *

Current premium amount paid. *

Reason Policy Expired

Previous Carrier *

Previous premium amount paid. *

Has your customer's business had any claims? *

Claims include fire, burglary, flooding, vandalism, etc.

Number of claims in past 3-5 years *

Number of full time employees. *

Number of part time employees. *

What are the gross receipts for your customer's business?

What is the annual revenue for your customer's business? *

If a Start Up - Please Estimate

What is the annual payroll for your customer's business?

Does your client or your client's business own the building?

What year was the building built? *

What is the construction type of the building? *

How many stories is the building? *

How many square feet is the building? *

What is the buildings roof type? *

Is there a burglar alarm in the building? *

Is there a fire alarm in the building? *

Are there smoke detectors in the building? *

Target/Estimated Premiums *

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COVERAGE FOR YOUR CLIENT'S BUSINESS

Liability coverage. *

Includes property damage on location, bodily injury on location, false advertising injury, and personal injury.

Building Coverage Amount *

Business personal property amount. *

Cost to replace your business personal property, including fixtures, equipment, furniture, cables, etc.

Property deductible.

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DOCUMENTS

Do you have all Acords on one file?

Acord 125 Form *

Acord 126 Form *

Acord 140 Form *

Acord 125, 126 & 140 Forms *

Declarations Page of Expiring/Expired Policy

Supplementals

Loss Runs (3 years Preferred/5 years Hard to Place)

Quote Needed for Additional Lines of Business?

Commercial Auto
EPL, D&O, Fiduciary, Crime & Tech Professional Liability
Miscellaneous Errors & Emissions (E&O)
Workers Comp
Commercial Umbrella/Excess
Fidelity & Surety Bonds
Inland & Ocean Marine
Cyber Liability
Owners & Contractors, and Railroad Protective - Construction Risk Only
Business Travel Accident (BTA)
Other Not Listed

Quote Needed for Additional Lines of Business?

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CERTIFY INFORMATION

Certify

I understand that the information provided herein is essential and material to the agency/broker relationship and herby certify the above answers are truthful and accurate, to the best of my knowledge.