Request Quote - Group Dental Insurance

Apply Online

If you would like to receive a quote for business insurance, please complete and submit this online application. If you would prefer to provide your information via telephone with a service representative, please call (949) 454-9400 for New Business Sales. We ensure the confidentiality of your information. Click here to review our privacy policy.

Mandatory fields

Please check the lines of insurance that you would like us to quote for you:

Property General Liability Workers Compensation Automobile

Information About Your Company

Name of Business

Legal Name of Business

Business Address

Mailing Address

Contact Person

Telephone

Fax

E-Mail Address

Website (if applicable)

How many years has the company been in business?

1-3 4-7 8-10 10+

Type of Industry

Please describe business operations:

Please enter total number of employees:

Full Time Part Time

Requested Coverage Effective Date (mm/dd/yy)

List current insurer(s)

Property Insurance

Primary Location

Do you own or lease this location?

Own Lease

Building Address

If you own the building, what is building replacement value?

What is the total value of your Business Personal Property?

(e.g. furniture, fixtures, equipment, machinery, stock, etc.)

What is the sq. footage of your current space/bldg?

sq. ft.

What is your building constructed of?

Does your building have an alarm?

Yes No

Is your building sprinklered?

Yes No

How many stories are in your building?

What floor is your office on?

Year of Construction (e.g. 1986)

If the building is over 30 years old, please describe current renovations:

Any losses at this location in the last 5 years?

Yes No

Please describe any losses, year of occurrence, description and total amount paid at this location.

Do you own or lease this location?

Own Lease

Building Address

If you own the building, what is building replacement value?

What is the total value of your Business Personal Property?

(e.g. furniture, fixtures, equipment, machinery, stock, etc.)

What is the sq. footage of your current space/bldg?

sq. ft.

What is your building constructed of?

Does your building have an alarm?

Yes No

Is your building sprinklered?

Yes No

How many stories are in your building?

What floor is your office on?

Year of Construction (e.g. 1986)

If the building is over 30 years old, please describe current renovations:

Any losses at this location in the last 5 years?

Yes No

Please describe any losses, year of occurrence, description and total amount paid at this location.

If you have more than one location, please contact our office at 949-454-9400

General Liability & Workers Compensation

General Liability Limit (per occurrence/aggregate)

Federal Employee Identification Number

(e.g. 123-45-6789)

Annual Revenues to Your Business

Employee Description

Annual Payroll

Executive Officers Excluded

Yes No

What percentage of your sales derive from

Internet-based sales?

Names of Officers and Corporate Titles

Umbrella Limit

Employer's Liability Limit

Any General Liability or WC losses in the last 5 years?

Yes No

Annual Payroll Amounts

Describe any losses/claims including year of

occurrence, description and total amounts paid.

Clerical - 8810

Outside Salespersons - 8742

Executive Officers - 8809

Other

Automobile Insurance

Hired and Non-Owned exposure only? (click for more info)

Yes No

Describe any auto losses/claims including year of

occurrence, description and total amounts paid.

Do you rent cars for business use?

Yes No

Vehicles
#	Year, Make and Model	VIN	Reg State	Usage Radius (miles)	Cost New	Garage Location (City)
1
2
3
4
5

Drivers
#	Driver Name	Date of Birth	License Number	Lic State	Describe any accident or moving violations in the past 5 years
1
2
3
4
5

If your application is complete, please click the Submit button below.

Once submitted, your information will be automatically transmitted to the Commercial Business Center

and you will be contacted by a Customer Service Representative within one business day.