Commercial Insurance Quote


We would like to provide you with a free, no-obligation commercial insurance quote.

Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

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Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

General Information
Name of Business:
Contact Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Email Address:
Best Time To Contact You:
AM   PM
How would you like to be contacted?:
Phone     Fax     Email     Regular Mail
Are you currently insured?:
Yes   No
Has your insurance ever been cancelled by the insurance carrier?:
Yes   No
Federal Tax ID#:
Describe your business operations:

Type of Commercial Insurance
Please select the type(s) of insurance that you are interested in:
  • Property
  • General Liability
  • Garage Coverage
  • Automobile
  • Workers Compensation
  • Umbrella
  • Other
  • Property Coverage
    Location Address:
    Location City:
    State:
    Zip:
    LIMITS:
    Building Limit:
    $
    Computers Limit:
    $
    Contents Limit:
    $
    Software Limit:
    $
    Business Income Limit:
    $
    Tools/Equipment:
    $
    Other:
    Other Amount:
    $
    BUILDING DETAILS:
    Year Built:
    Building Construction:
    Roof Type:
    Total Area:
    # of stories:
    Basement:
    Units:

    General Liability Coverage
    Location Address:
    Location City:
    State:
    Zip:
    Description of each type of function/operation at this location:
    Gross Annual Sales:
    $
    Annual Payroll:
    $
    Area/#units:
    Description of each type of function/operation at this location:
    Gross Annual Sales:
    $
    Annual Payroll:
    $
    Area/#units:
    Description of each type of function/operation at this location:
    Gross Annual Sales:
    $
    Annual Payroll:
    $
    Area/#units:
    Do you provide health insurance to your employees?:
    Yes   No
    Does your company issue guarantees, warranties or hold harmless agreements?:
    Yes No
    Do you have a commercial auto policy?:
    Yes No
    Does your company install, service or demonstrate any products?:
    Yes No
    Does your company sell any foreign products?:
    Yes No
    Does your company re-package or sell any products of others under your name?:
    Yes No
    Do you draw plans, designs or specifications for other?:
    Yes No
    Do you subcontract work to others?:
    Yes No
    If yes (above), what percentage of your work is subbed out?:
    %

    Garage Coverage
    If you are interested in Garage Coverage, please call us at the number below to discuss further:
    Phone: 734-446-2722 or Toll Free: 1-888-606-4413

    Automobile Coverage
    Drivers Name:
    Date of Birth:
    Drivers License #:
    State Licensed:
    Drivers Name:
    Date of Birth:
    Drivers License #:
    State Licensed:
    Drivers Name:
    Date of Birth:
    Drivers License #:
    State Licensed:
    Year:
    Make/Model:
    VIN#:
    Cost New:
    $
    City Garaged:
    Year:
    Make/Model:
    VIN#:
    Cost New:
    $
    City Garaged:
    Year:
    Make/Model:
    VIN#:
    Cost New:
    $
    City Garaged:
    Year:
    Make/Model:
    VIN#:
    Cost New:
    $
    City Garaged:
    Year:
    Make/Model:
    VIN#:
    Cost New:
    $
    City Garaged:
    Are the vehicles above titled in any name other than the business name?:
    Yes   No
    Do you travel in a radius greater than 50 miles from your business?:
    Yes   No
    If yes, how far?:
    Are Motor Vehicle Reports ordered for all drivers prior to hiring?:
    Yes   No
    Are any drivers not covered under a workers compensation policy?:
    Yes   No

    Workers' Compensation Coverage
    Officer Name:
    Title:
    Ownership:
    Include/Exclude*:
    Include   Exclude
    Salary (if included):
    $
    Officer Name:
    Title:
    Ownership:
    Include/Exclude*:
    Include   Exclude
    Salary (if included):
    $
    Officer Name:
    Title:
    Ownership:
    Include/Exclude*:
    Include   Exclude
    Salary (if included):
    $
    *Please note, if excluded, your health insurance may not cover all work related claims.
    Please list each duty performed:
    Clerical
    Class code (if known):
    # full time employees:
    # part time employees:
    Annual Payroll:
    $
    Please list each duty performed:
    Sales
    Class code (if known):
    # full time employees:
    # part time employees:
    Annual Payroll:
    $
    Please list each duty performed:
    Class code (if known):
    # full time employees:
    # part time employees:
    Annual Payroll:
    $
    Please list each duty performed:
    Class code (if known):
    # full time employees:
    # part time employees:
    Annual Payroll:
    $
    Please list each duty performed:
    Class code (if known):
    # full time employees:
    # part time employees:
    Annual Payroll:
    $
    Please list each duty performed:
    Class code (if known):
    # full time employees:
    # part time employees:
    Annual Payroll:
    $
    Do you provide health insurance for 75% or more of your employees?:
    Yes   No
    Do you have a formal written safety program/manual in place?:
    Yes   No
    Federal Tax ID#:

    Umbrella Coverage
    Limit of Insurance:
    $

    Other Coverage
    If you are interested in Other Coverage, please call us at the number below to discuss further:
    Phone: 734-446-2722 or Toll Free: 1-888-606-4413

    Additional Comments
    Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

    Please click on the "Submit Quote" button to send your quote request.
    One of our representatives will respond to your submission as soon as possible.

     
     
     
    Call us today!
    Your insurance agent at Pietila Insurance Agency, Inc. can help you get the BEST coverage at the BEST rate for your business insurance!

    Call (888)PIETILA for your consultation today!