Business Owners Quote Form
Business Quote
Contact Name*
Email*
Business Name
Address
City
State
Zip Code
County
Business Phone
Fax
Company Name
Address
Occupancy Status
Year Built
% Occupied
Sprinklers
No
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm
No
Building Value
Contents
Describe any claims you have
had in the past 5 years
Serving the Pittsburgh Area for 60 Years
*Fill out the form and then click submit at the bottom of this page and we will begin
working on a price for you.
Current Insurance Company
(not agency)
Policy Expiration Date
Current Insurance
Coverages
 Bond
Commercial Auto
Commercial Liability
Commercial
Property
Commercial
Umbrella
Professional Liability
Workers'
Compensation
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business?
(yrs)
How many locations?
Brief description of your
business and clientele
Property/ Premises Information
Yes
Yes
Other Property
(specify)
Insurance Information
Annual Gross Sales
Number of Employees
Annualized Payroll
Cost of any Subcontracted
Work
Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Additional Comments
Four Clairton Blvd. P.O. Box 18069 Pittsburgh, PA 15236     Phone: 412.892.2424   Fax: 412.653.9463
EMAIL