Business Insurance Quote Form

Welcome to Weber Insurance's Business quote form.  To request a quote, please complete as much of the form as possible.  Use the Tab key to move from field to field.  If you leave the form, use the back button on your browser to return to the form.  This form will be emailed to us.  All information entered is confidential.

DO NOT USE THE "ENTER" KEY

USE THE "TAB" KEY  

OR YOUR MOUSE

TO MOVE FROM FIELD TO FIELD.
 

 

 
Contact Information
Your Name:  
 Mailing Address:  
City:  
State:  
Zip Code:  
Daytime phone:  
Evening Phone:
FAX:
Email Address:

 

Business Information

Name of business:  

  

Federal ID # (or your SS #):  

  

Form of ownership:  

  

How long has this entity been in business:  

How much experience do you have in this type of business:

Did you have bottom line responsibility?    

  

 What date do you need the to be effective?  

  

What is the nature and description of your business?

How much is your estimated annual gross sales?

How much is your annual payroll excluding officers and owners?
List Claims made in the last four years

What is the name of your present insurance company?
Type of  claim:     
Date of Claims:   

Amount Paid by Insurance $  

Details of claims:  

 During the past 4 years, has any coverage been cancelled, non-renewed, declined, or placed in non-standard markets (non-standard markets charge tax)

Yes     No

 

Business Location
Address    
City  
State    
Zip Code  
County and Township  
Distance to Fire Hydrant  
Distance to Fire Station  

Size and Age

Construction of Building  
Nature of business 

Number of Stories excluding basement   

Does the building have a basement?  Yes     No

  What floor is business located 

Check all that apply

     First floor

     Second floor   

     Third floor

     Fourth floor

     Basement

       

What year was it built (approximate)?  

Approximate square feet of business?  

 
Approximate total square feet in building?  
What is on the left of your business?  
What is on the right of your business?  
What is behind your business?  
 If the building has apartments, how many?  
 Do you (or the business) own the building?  

Yes  No

Burglar Alarms?  
 Fire Alarms?  
Sprinklers in building?  
Updates to Building
Roof type   Flat    Peaked
Roof last replaced  
Heat type  
Heater last replaced  
If oil heat, where is tank? 
Electrical system  
 Circuit breakers     Yes       No
Electric last updated  
Plumbing type  
Plumbing last updated  

 

Insurance Coverages

Building coverage (If you own it) $  

Tenants improvements $  

Inventory coverage $  

Furniture and fixtures coverage $  

Computers and software coverage $  

Premises liability per occurrence $  

Products & Completed Operations $  

Your Fire Legal Liability  $   

Medical Payments Amount $   

Deductible Amount  $   

 

Remarks

 

 Be patient, it will take some time for the information to be processed.  A Form Confirmation will be displayed.  Please review the information you entered.  If you need to correct any information, use the "Back" arrow on your browser to return to the form with the data you entered still in the form.  Clicking on "Return to the Form" will erase all data and return you to an empty form.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.

Are you ready to send this information? (type "YES")