Commercial Umbrella Quote Form – Ramsgate Insurance

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Do you have completed Accords (125,131)? *

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 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? *

Agent/Broker/Rep

Website URL

Agent/Broker/Rep

Does the Agency/Brokerage have multiple locations? *

Agent/Broker/Rep

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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

Agent/Broker/Rep

Contact Email1 *

Agent/Broker/Rep

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YOUR CLIENTS BUSINESS LOCATION INFORMATION

Business Name *

Include DBA, if applicable. First Named Insured

Address Line 1 *

Clients Business Information

Address Line 2

Clients Business Information

City *

Clients Business Information

State Code *

Clients Business Information

Zip Code *

Clients Business Information

Business Phone *

Clients Business Information

Business Ext

Clients Business Information

Business Fax

Clients Business Information

Date Business Started *

MM/DD/YEAR

What is the legal structure of your client'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 *

Clients Business Information

Primary Contact Middle Name

Clients Business Information

Primary Contact Last Name *

Clients Business Information

Mobile Phone

Clients Business Information

Contact Email2 *

Clients Business Information

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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 client's business?

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

If a Start Up - Please Estimate

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

Does your client or your client's business own their building? *

Target/Estimated Premium *

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COVERAGE FOR YOUR CLIENT'S BUSINESS

Limit Request *

In the last 3 years, has any insurance company either declined to issue a policy, or cancelled, or failed to renew existing coverage for the business? *

If the account is not concurrent with underlying coverages or is being marked mid-term, please provide details:

Does the business own any aircraft? *

Does the business have a Workers' Compensation Policy? *

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DOCUMENTS

Do you have all Acords on one file? *

Acord 125 Form *

Acord 131 Form *

Acord 125 & 131 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?

BOP
General Liabililty
Commercial Property
Commercial Auto
EPLI, D&O, Fiduciary, Crime & Tech Professional Liability
Miscellaneous Errors & Emissions (E&O)
Inland & Ocean Marine
Workers Comp
Fidelity & Surety Bonds
Cyber Liability
Business Travel Accident (BTA)
Other Not Listed

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CERTIFY INFORMATION

Certify *

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