Houston, TX 77054
1 (800) 528-0750
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Personal Risk
Homeowner’s
Auto
Life
Health
Renter’s
Flood
Personal Umbrella
Commercial Risk
Business Owner’s Policy
Commercial Property
General Liabilty Insurance
Commercial Auto Insurance
Commercial Flood Insurance
Workers Compensation
Group Life Insurance
Group Health Insurance
About Us
FAQs
Contact Us
Business Information Quote
Bio Information
Whats your policy start date?
MM slash DD slash YYYY
What is the Legal name of your business?
Doing Business As?
Yes
No
Doing Business As
FEIN
Business Formation
Business Formation
Individual
Partnership
Corporation
LLC
Not for profit
Joint Venture
Business Address
Mailing Address?
Yes
No
Primary Contact Name
Contact Type
Email
Phone Number
Website
What is your business start date?
MM slash DD slash YYYY
How many years of Industry experience?
Describe your business operations and any working exposures in as much detail as possible.
Type of business insurance requested
General Liability
Property Coverage
Workers Compensation
Excess Liability
Business Auto (NTL/APD)
General Liability
Premises Information
Location #1
Is Business Address same as Location 1 address?
Yes
No
Address
Address
Square Feet?
Occupancy Type?
Occupancy Type?
Owner
Tenant
Full Time Employees
Part Time Employees
What is your expected total sales in the next 12 months?
What is your expected payroll over the next 12 months?
Description of Location Operations
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add additional location
Add additional location
#2 Premises Information
Location #2
Is Business Address same as Location 2 address?
Yes
No
Address
Address
Square Feet?
Occupancy Type?
Occupancy Type?
Owner
Tenant
Full Time Employees
Part Time Employees
What is your expected total sales in the next 12 months?
What is your expected payroll over the next 12 months?
Description of Location Operations
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add additional location
Add additional location
#3 Premises Information
Location #3
Is Business Address same as Location 3 address?
Yes
No
Adress
Adress
Square Feet?
Occupancy Type?
Occupancy Type?
Owner
Tenant
Full Time Employees
Part Time Employees
What is your expected total sales in the next 12 months?
What is your expected payroll over the next 12 months?
Description of Location Operations
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Property Coverage
Premises Information
Location #1
Is Business Address same as Location 1 address?
Yes
No
Address
Address
Square Feet?
Do you need property coverage for this location?
Yes
No
Building Value
Year Built
Building Construction type
Building Construction type
Frame
Brick Veneer
Stucco
Masonry
Roof Type
Roof Type
Composition
Metal
Slate
Tile
Other
Burglar Alarm
Burglar Alarm
None
Local
Central
Fire Alarm
Fire Alarm
None
Local
Central
Is your building equipped with fire sprinklers?
Yes
No
Building Improvements in recent years?
Building Improvements in recent years?
Wiring
Roofing
Plumbing
Heating
None
Have Business Personal Property? (Furniture, Computers, etc.)
Yes
No
Please enter the details of personal property
Have Inventory?
Yes
No
Have Inventory
Want to protect your Business Income?
Yes
No
How much in income protection each month?
Do you need flood coverage?
Yes
No
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add additional location
Add additional location
#2 Premises Information
Location #2
Is Business Address same as Location 1 address?
Yes
No
Address
Address
Square Feet?
Do you need property coverage for this location?
Yes
No
Building Value
Year Built
Building Construction type
Building Construction type
Frame
Brick Veneer
Stucco
Masonry
Roof Type
Roof Type
Composition
Metal
Slate
Tile
Other
Fire Alarm
Burglar Alarm
None
Local
Central
Fire Alarm
Burglar Alarm
None
Local
Central
Is your building equipped with fire sprinklers?
Yes
No
Building Improvements in recent years?
Building Improvements in recent years?
Wiring
Roofing
Plumbing
Heating
None
Have Business Personal Property? (Furniture, Computers, etc.)
Yes
No
Please enter the details of personal property
Have Inventory?
Yes
No
Please enter the information
Want to protect your Business Income?
Yes
No
How much in income protection each month?
Do you need flood coverage?
Yes
No
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add additional location
Add additional location
#3 Premises Information
Location #3
Is Business Address same as Location 1 address?
Yes
No
Address
Address
Square Feet?
Do you need property coverage for this location?
Yes
No
Building Value
Year Built
Building Construction type
Building Construction type
Frame
Brick Veneer
Stucco
Masonry
Roof Type
Roof Type
Composition
Metal
Slate
Tile
Other
Burglar Alarm
Burglar Alarm
None
Local
Central
Fire Alarm
Fire Alarm
None
Local
Central
Is your building equipped with fire sprinklers?
Yes
No
Building Improvements in recent years?
Have Business Personal Property? (Furniture, Computers, etc.)
Yes
No
Please enter the details of personal property
Have Inventory?
Yes
No
Please enter the information
Want to protect your Business Income?
Yes
No
How much in income protection each month?
Do you need flood coverage?
Yes
No
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
MM slash DD slash YYYY
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Workers Compensation
Desired Employers’ Liability Limits
Desired Employers’ Liability Limits
$100k/$500k/$100k
$500k/$500k/$500k
$1m/$1m/$1m
How many owners/officers do you have?
Owners/Officers
Name
Title
Duties
Payroll/Compensation
Ownership %
Included or Excluded from policy
Do you use subcontractors?
Yes
No
Provide percentage of work subcontracted
Use volunteer or donated labor?
Yes
No
Does the insured have any employees that drive more than 10% of the time?
Yes
No
Perform any work underground or above 15 feet?
Yes
No
% of The Time
Have a written safety program in operation?
Yes
No
Provide an employee health plan?
Yes
No
Have an employee wellness program in place?
Yes
No
Have a return-to-work program?
Yes
No
Waiver of subrogation needed?
Yes
No
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Excess Liability
Which lines of business are you requesting Excess Liability
Business Auto
Commercial
General Liability
Crime Liability
Professional Liability
Workers Compensation
Liquor Liability
Are you currently Covered?
Yes
No
Do you currently have a policy in place?
Yes
No
Carrier
Premium
Expiration date
MM slash DD slash YYYY
Have you had any claims?
Yes
No
Have you filed any claims?
Yes
No
Date of Occurrence
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Add another
Add another
Date of Occurrence
Description
Amount paid
Has your claim been closed out
MM slash DD slash YYYY
Business Auto (NTL/APD)
Vehicles
Vehicle Type
Vehicle Type
Car Carrier
Pickup Truck**
Tow Truck
Flatbed Truck
Truck Tractor
Trailer**
Other
What is the gross vehicle weight (Weight of vehicle + Weight of load)?
What is the gross vehicle weight (Weight of vehicle + Weight of load)?
6,000 or less
6,001 to 10,000
10,001 to 14,000
14,001 to 16,000
16,001 to 19,500
Unknown
What is the vehicles tonnage?
What is the vehicles tonnage?
½ ton or less
¾ ton or more
How many driving wheels does the vehicle have?
How many driving wheels does the vehicle have?
4 x 2
4 x 4
What type of trailer hitch does this vehicle have?
What type of trailer hitch does this vehicle have?
None
5th Wheel
Tow Boom
Ball at bumper
Ball in bed
Gooseneck
What type of trailer?
What type of trailer?
Gooseneck Trailer
Utility Trailer
Auto Hauler
Flatbed Trailer
Travel Trailer
Other
Other
VIN
Make
Model
Year
Garaging Address
Farthest one-way distance this vehicle typically travels (90% or more of the time)
Farthest one-way distance this vehicle typically travels (90% or more of the time)
50 miles
100 miles
200 miles
300 miles
500 miles
More than 500 miles
Is there a loan/lease on this vehicle?
Yes – Loan
Yes – Lease
No
Do you have permanently attached equipment?
Yes
No
What is the value of the permanently attached equipment?
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?
Do you need Comprehensive or Collision coverage?
Yes
No
Do you have permanently attached equipment?
Yes
No
What is the value of the permanently attached equipment?
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?
Add additional vehicle
Add additional vehicle
#2 Vehicles
Vehicle Type
Vehicle Type
Car Carrier
Pickup Truck**
Tow Truck
Flatbed Truck
Truck Tractor
Trailer**
Other
What is the gross vehicle weight (Weight of vehicle + Weight of load)?
What is the gross vehicle weight (Weight of vehicle + Weight of load)?
6,000 or less
6,001 to 10,000
10,001 to 14,000
14,001 to 16,000
16,001 to 19,500
Unknown
What is the vehicles tonnage?
What is the vehicles tonnage?
½ ton or less
¾ ton or more
How many driving wheels does the vehicle have?
How many driving wheels does the vehicle have?
4 x 2
4 x 4
What type of trailer hitch does this vehicle have?
What type of trailer hitch does this vehicle have?
None
5th Wheel
Tow Boom
Ball at bumper
Ball in bed
Gooseneck
What type of trailer?
What type of trailer?
Gooseneck Trailer
Utility Trailer
Auto Hauler
Flatbed Trailer
Travel Trailer
Other
Other
VIN
Make
Model
Year
Garaging Address
Farthest one-way distance this vehicle typically travels (90% or more of the time)
Farthest one-way distance this vehicle typically travels (90% or more of the time)
50 miles
100 miles
200 miles
300 miles
500 miles
More than 500 miles
Is there a loan/lease on this vehicle?
Yes – Loan
Yes – Lease
No
Do you have permanently attached equipment?
Yes
No
What is the value of the permanently attached equipment?
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?
Do you need Comprehensive or Collision coverage?
Yes
No
Do you have permanently attached equipment?
Yes
No
What is the value of the permanently attached equipment?
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?
Add additional vehicle
Add additional vehicle
#3 Vehicles
Vehicle Type
Vehicle Type
Car Carrier
Pickup Truck**
Tow Truck
Flatbed Truck
Truck Tractor
Trailer**
Other
What is the gross vehicle weight (Weight of vehicle + Weight of load)?
What is the gross vehicle weight (Weight of vehicle + Weight of load)?
6,000 or less
6,001 to 10,000
10,001 to 14,000
14,001 to 16,000
16,001 to 19,500
Unknown
What is the vehicles tonnage?
What is the vehicles tonnage?
½ ton or less
¾ ton or more
How many driving wheels does the vehicle have?
How many driving wheels does the vehicle have?
4 x 2
4 x 4
What type of trailer hitch does this vehicle have?
What type of trailer hitch does this vehicle have?
None
5th Wheel
Tow Boom
Ball at bumper
Ball in bed
Gooseneck
What type of trailer?
What type of trailer?
Gooseneck Trailer
Utility Trailer
Auto Hauler
Flatbed Trailer
Travel Trailer
Other
Other
VIN
Make
Model
Year
Garaging Address
Farthest one-way distance this vehicle typically travels (90% or more of the time)
Farthest one-way distance this vehicle typically travels (90% or more of the time)
50 miles
100 miles
200 miles
300 miles
500 miles
More than 500 miles
Is there a loan/lease on this vehicle?
Yes – Loan
Yes – Lease
No
Do you have permanently attached equipment?
Yes
No
What is the value of the permanently attached equipment?
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?
Do you need Comprehensive or Collision coverage?
Yes
No
Do you have permanently attached equipment?
Yes
No
What is the value of the permanently attached equipment?
If this vehicle was sold today, how much would it be worth (excluding any permanently attached equipment)?
Drivers
Name
DOB
MM slash DD slash YYYY
Driver License State
Driver License Number
Has a CDL?
Yes
No
Have you had any accidents or violations in the past 5 years?
Yes
No
Date of Incident
MM slash DD slash YYYY
Type of Accident/Violation
Add another driver
Add another driver
#2 Drivers
Name
DOB
MM slash DD slash YYYY
Driver License State
Driver License Number
Has a CDL?
Yes
No
Have you had any accidents or violations in the past 5 years?
Yes
No
Date of Incident
MM slash DD slash YYYY
Type of Accident/Violation
Add another driver
Add another driver
#3 Drivers
Name
DOB
MM slash DD slash YYYY
Driver License State
Driver License Number
Has a CDL?
Yes
No
Have you had any accidents or violations in the past 5 years?
Yes
No
Date of Incident
MM slash DD slash YYYY
Type of Accident/Violation
Insurance History
Are you currently insured? Personal Auto policies also qualify as proof of prior insurance.
Yes
No
Carrier
Expiration Date
MM slash DD slash YYYY
Have you had continuous coverage for at least one year?
Bodily Injury and Property Damage Liability
Do you have any other business insurance?
General Liability
Business Owner’s Policy
None
Is a Blanket Additional Insured endorsement needed by contract?
Yes
No
Is a Blanket Waiver of Subrogation endorsement needed by contract?
Yes
No
Are state or federal filings required?
Yes
No
Coverages
Bodily Injury and Property Damage Liability
Bodily Injury and Property Damage Liability
Not selected
$30k/$60k/$25k
$50k/$100k/$25k
$100k/$300k/$50k
$250k/$500k/$100k
$100k CSL
$300k CSL
$500k CSL
$750k CSL
$1M CSL
Uninsured/Underinsured Motorist Bodily Injury
Uninsured/Underinsured Motorist Bodily Injury
Not selected
$30k/$60k/$25k
$50k/$100k/$25k
$100k/$300k/$50k
$250k/$500k/$100k
$100k CSL
$300k CSL
$500k CSL
$750k CSL
$1M CSL
Uninsured Motorist Property Damage
Uninsured Motorist Property Damage
$25k
$50k
Personal Injury Protection
Personal Injury Protection
Not Selected
$2,500
$5,000
$10,000
$25,000
Comprehensive
Comprehensive
Not selected
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
$2,500 Deductible
$5,000 Deductible
Collision
Collision
Not selected
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
$2,500 Deductible
$5,000 Deductible
Rental Reimbursement
Rental Reimbursement
Selected
Not Selected
Roadside
Roadside
Selected
Not Selected
Fire & Theft w/ Combined Additional Coverage
Fire & Theft w/ Combined Additional Coverage
Not selected
$100 Deductible
$250 Deductible
$500 Deductible
$1,000 Deductible
$2,500 Deductible
$5,000 Deductible
Do you need Motor Truck Cargo?
Yes
No
Does the customer require cargo coverage for mobile homes?
Yes
No
Does the customer require cargo coverage for business documents or non-negotiable securities?
Yes
No
Does the customer require Refrigeration Breakdown coverage?
Yes
No
Please list the top 4 commodities you hail on a regular basis.
Personal Risk
Homeowner’s
Auto
Life
Health
Renter’s
Flood
Personal Umbrella
Commercial Risk
Business Owner’s Policy
Commercial Property
General Liabilty Insurance
Commercial Auto Insurance
Commercial Flood Insurance
Workers Compensation
Group Life Insurance
Group Health Insurance
About Us
FAQs
Contact Us