Get a Quote for Business Insurance

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Get a Quote for Business Insurance

If you would like a preliminary quote for any of your business insurance needs, please complete Section 1 of the following form, and then complete ONLY those sections that apply to the specific type of quote or quotes you desire. Be sure to select at least one type of quote, and click on "Send" at the bottom of the page after completing the form. We will review your application and provide a quote as quickly as possible. If we need more information, we will contact you.

Questions? Please feel free to contact us!

Form Master

Section 1: Personal Information

Your Complete Name:

Your Complete Email Address:

Applicant’s First Name:

Applicant’s Last Name:

Street Address:

Apt., Suite or Other:

City:

State:

Zip Code:

Spouse’s First Name:

Spouse’s Last Name:

Applicant’s Home Phone (with Area Code):

Applicant’s Work Phone (with Area Code):

Applicant’s Mobile Phone (with Area Code):

Best Way to Contact Applicant?

Do You Currently Have Business Insurance with Another Carrier?

Yes
No

If Yes, With Which Company?

Type of Business Entity:

Nature of Business:

How Long Have you Been in Business?

What Type(s) of Insurance Coverage are you Requesting? (Check all that Apply)

General Liability (Complete Section 2 Below)
Worker's Compensation (Complete Section 3 Below)
Commercial Property (Complete Section 4 Below)
Commercial Auto (Complete Section 5 Below)
Commercial Umbrella (Complete Section 6 Below)
Group Health (Complete Section 7 Below)

Section 2: General Liability Quote
(Skip this section if you do not need a general liability quote)

Amount of Coverage Desired:

Number of Employees (other than the owner):

Estimated Gross Sales (annual):

Section 3: Worker's Compensation Quote
(Skip this section if you do not need a worker's compensation quote)

Number of Employees:

Estimated Annual Payroll for Employees:

Section 4: Commercial Property Quote
(Skip this section if you do not need a commercial property quote)

Property Street Address (include City, State, Zip Code):

Amount of Coverage for Builiding (if owned):

Amount of Coverage for Business Contents or Tools/Equipment:

Section 5: Commercial Auto Quote
(Skip this section if you do not need a commercial property quote)

Are you currently covered on an auto policy?

Yes
No

Bodily Injury Limits Desired (Applies to all vehicles on this policy):

Please provide information for up to four vehicles to be insured below:

Vehicle 1:

Vehicle 1 Year:

Vehicle 1 Make (examples: Chrysler, Ford):

Vehicle 1 Model (examples: Sebring, Mustang, etc.):

Vehicle 1 Identification Number (VIN):

Do you want full coverage for Vehicle 1?

Yes
No

If you answered "Yes" to full coverage for Vehicle 1...

Deductible Requested for Vehicle 1:

Vehicle 2:

Vehicle 2 Year:

Vehicle 2 Make:

Vehicle 2 Model:

Vehicle 2 VIN:

Do you want full coverage for Vehicle 2?

Yes
No

If you answered "Yes" to full coverage for Vehicle 2...

Deductible Requested for Vehicle 2:

Vehicle 3:

Vehicle 3 Year:

Vehicle 3 Make:

Vehicle 3 Model:

Vehicle 3 VIN:

Do you want full coverage for Vehicle 3?

If you answered "Yes" to full coverage for Vehicle 3...

Deductible Requested for Vehicle 3:

Vehicle 4:

Vehicle 4 Year:

Vehicle 4 Make:

Vehicle 4 Model:

Vehicle 4 VIN:

Do you want full coverage for Vehicle 4?

Yes
No

If you answered "Yes" to full coverage for Vehicle 4...

Deductible Requested for Vehicle 4:

Please provide information for up to four drivers to be insured below:

Driver 1 Information:

Driver 1 First Name:

Driver 1 Last Name:

Driver 1 Date of Birth (MM/DD/YYYY):

Driver 1 License Number:

Driver 1 License State of Issue:

Driver 2 Information:

Driver 2 First Name:

Driver 2 Last Name:

Driver 2 Date of Birth (MM/DD/YYYY):

Driver 2 License Number:

Driver 2 License State of Issue:

Driver 3 Information:

Driver 3 First Name:

Driver 3 Last Name:

Driver 3 Date of Birth (MM/DD/YYYY):

Driver 3 License Number:

Driver 3 License State of Issue:

Driver 4 Information

Driver 4 First Name:

Drvier 4 Last Name:

Driver 4 Date of Birth (MM/DD/YYYY):

Driver 4 License Number:

Driver 4 License State of Issue:

Section 6: Commercial Umbrella Quote
(Skip this section if you do not need a commercial umbrella quote)

Amount of Coverage Desired:

Section 7: Group Health Quote
(Skip this section if you do not need a commercial umbrella quote)

Current Carrier (if applicable):

Number of Employees:

Additional Information

Please provide any additional information we should consider in preparing your quote(s):

Thank you for completing the form. Please enter the security code below, which helps us confirm that an actual human being completed this form. Then click "submit" below.

Do you need a response within 24 hours?

Yes
No

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201 Capitol Avenue | Frankfort, KY 40601 | 502.875.1351

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