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Name
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First
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Phone
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Insurance State Contact
Email
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Preferred Method of Contact
Call
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Email
City, State (Illinois only)
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Address
Insurance Type
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Home Insurance
Auto Insurance
Life Insurance
Business Insurance
Trucking Insurance
Pet Insurance
General Liability Insurance
Workers’ Compensation Insurance
Additional Comment
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I agree to be contacted by Merrill Insurance Agency, Inc. regarding my quote request.
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Personal
Home
Auto
Life
Business
Commercial Auto
Workers Compensation
Trucking
Pet
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General liability Application
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Name
*
First
Last
Phone
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Email
*
Preferred Method of Contact
Call
Text
Email
City, State (Illinois only)
*
Business Information
Legal Business Name
*
DBA (if applicable)
*
FEIN
*
Business Structure
Sole Proprietor
Partnership
LLC
Corporation
Business Address
*
Years in Business
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Operations & Business Details
Description of Business Operations
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(full time/part time)
Primary Industry / Business Type
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(full time/part time)
Annual Gross Revenue ($)
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Number of Employees
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Do you perform work at client locations?
*
Yes
No
Do you subcontract any work?
*
Yes
No
If yes, do subcontractors carry their own insurance?
*
Yes
No
Do you require certificates of insurance from subcontractors?
*
Yes
No
Coverage Information
Coverage Type Requested:
*
General Liability
Professional Liability
Product Liability
Contractor Liability
Event Liability
Desired Coverage Limit
*
$500,000
$1,000,000
$2,000,000
Not Sure (Recommend Best Option)
Desired Policy Effective Date
*
Property & Risk Exposure (If Applicable)
Do you own or lease commercial property?
*
Yes
No
Total Square Footage
Number of Locations
Any warehouse, storage, or manufacturing operations?
*
Yes
No
Any hazardous materials used or stored?
*
Yes
No
Do do or
Claims & Insurance History
Current Insurance Carrier (if any)
Policy Expiration Date
*
Any workers comp claims in the past 5 years?
*
Yes
No
If yes, please describe
Consent
I agree to be contacted by Merrill Insurance Agency, Inc. regarding my quote request.
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