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Insure 2 Secure
Business Insurance Quote Form
Please enter your information below. All information provided will be kept safe and secure and will be used to give you the most accurate quotes. If you prefer to speak to one of our agents directly or would like help filling out this form, please call us at 1.203.404.1140.
Company Information
Please enter your company's information below. It is OK to estimate some values if you are not sure, but providing correct information will allow insurance agents to provide more accurate quotes.
Company name
Legal classification
-- Choose One --
C Corporation
S Corporation
Limited Liability Company
Limited Liability Partnership
Partnership
Sole Proprietorship
Limited Partnership
Professional Corporation
Nonprofit Corporation
Municipality
Trust
Other / Not Sure
Years in business (OK to estimate)
Annual revenue (OK to estimate)
-- Choose One --
Less than $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
More than $10,000,000
Gross annual payroll (OK to estimate)
-- Choose One --
Less than $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $5,000,000
$5,000,000 - $10,000,000
More than $10,000,000
Number of owners (OK to estimate)
Number of full-time employees (OK to estimate)
Number of part-time employees (OK to estimate)
Four digit SIC code (enter 9999 if you can't find it)
Employer Identification Number (EIN)
Personal Information
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
Zip / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone
Email
Social Security Number
Birthdate
Coverage Information
What coverage type are you primarily interested in?
-- Choose One --
Business Owners Policy
Commercial Auto
Commercial Property
Worker's Compensation
Liability Insurance
Business Interruption Insurance
Commercial Crime
Business Umbrella
Employment Practices Liability
Executive Deferred Compensation
401k/Retirement Plans
Group Disability Insurance
Group Life
Key Man Life Insurance
Key Man Disability Insurance
Supplemental Plans
Group Health
Bonds
Is the business property owned or leased?
Owned
Leased
Other
Number of square feet the business occupies
(OK to estimate)
Business Hours (open)
:
HH
MM
AM
PM
Business Hours (close)
:
HH
MM
AM
PM
Does the business's hours of operation include weekends?
Yes
No
Years mgmt experience of owner in industry
(OK to estimate)
Brief description of business
Which Additional coverage types are you interested in?
Business Owners Policy
Worker's Compensation
Commercial Auto
Commercial Property
Liability Insurance
Business Interruption Insurance
Commercial Crime
Business Umbrella
Employment Practices Liability
Executive Deferred Compensation
401k/Retirement Plans
Group Disability Insurance
Group Life
Key Man Life Insurance
Key Man Disability Insurance
Supplemental Plans
Group Health
Bonds
Type of Insurance:
Auto Insurance
Home Insurance
Renters Insurance
Business Insurance
Motorcycle/ATV
Boat/PWC
RV Insurance
Your ZIP Code:
Are you currently insured?
Yes
No
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