Southern Insurance Agency

Business Quote

Please Note:
Business Quotes are available to North Carolina and Virginia residents only.

GENERAL INFORMATION
Contact Name *
Email *

Business Name
Mailing Address
City
State
Zip
County
Business Phone
Fax
CURRENT INSURANCE COMPANY
(not agency)
Company Name
Policy Expiration Date
REQUESTED INSURANCE COVERAGES
Requested Coverages Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
BUSINESS INFORMATION
Type of Entity
(Please select one)
Individual/Sole Proprietor
C Corporation
S Corporation
Limited Liability Company (LLC)
Partnership
Trust/Estate
# of Owners/Officers
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
PROPERTY/PREMISES INFORMATION
Same as Mailing Address Yes  No
Primary Physical Address
City
State
Zip
Occupancy Status Owner  Tenant
Year Built
% Occupied
Sprinklers Yes  No
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm Yes  No
Building Value
Contents Value
Other Property (specify)
Ex: Wooden Outdoor Sign $5,000
INSURANCE INFORMATION
Annual Gross Sales:
Before Taxes
Annualized Payroll
Not Including Owner(s) Payroll
Cost of any Subcontracted Work
Describe types of Subcontractors you use
Limits Requested
Per Occurrence
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Weather for KITTY HAWK, NC
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