Commercial Insurance Form



Please fill in the following form:
Contact Name:
Company Name:
Address:
City, State, Zip:
Phone:
Fax:
E-mail:

Describe the business's operations:

What is the desired effective date?
How long in business?
Do you have insurance presently?
If yes provide copies of existing coverage.
What is your current premium?
How many employees do you have?
How many square feet is your premises?
What is your estimated annual gross income?

What coverage are you looking for?
General Liability Limit
Commercial Property Building Limit Contents
Workers Comp? # Employees Annual Payroll
Commercial Auto (Requires completed auto form)

Any Other Coverage Needed?

Are there any Additional Insureds or Mortgagees? If yes, provide info:

Type:
Name:
Address:
City, State Zip:

Any other additional information?

 

 

 

Wike Insurance Services
Tel: 727-446-9009
FAX: 727-298-8414
E-mail: info@WikeInsurance.com