Quote/Business – Zurita Insurance & Financial Services

Agent Submitting this Request:

Submitted By: *

How can we help protect your business?

You may choose more than one.

What type of insurance do you need? *

Business Owners
General Liability
Workers' Compensation
Commercial Auto
Umbrella
Commercial Property
Professional Liability
Other (describe below)

Other Coverage *

Are you working with one of our Agents? *

Agent Name *

Great, please tell us about yourself!

Applicant Name *

First

Last

Business Name (if applicable)

Business Type *

Individual / Sole Proprietor
Limited Liability Company (LLC)
Corporation
Association
Limited Liability Partnership (LLP)
Trust

Phone *

Email *

Applicant Address *

Address Line 1

City

State

Zip Code

Preferred Language *

English
Spanish
Portuguese

Tax ID / Federal Employer Identification Number / Social Security Number *

*Required for workers compensation

Tell us about your business!

Are you a contractor? (carpenter, painter, landscaper, etc.)

Business Type *

Work being performed:

Class of business *

Please provide a brief description of the products/services that you offer: *

What year did you start your business? *

How long have you maintained continuous insurance? *

Please explain the reason for no prior insurance: *

What are your estimated annual gross sales? *

Do you have W2 employees? *

Number of Employees: *

Annual Payroll: *

Do you hire subcontractors? *

% of work completed by subcontractors: *

How much liability coverage do you need? *

Do you have a physical business location? *

Yes
No, I use my home address

Approximately how many square feet does your business occupy? *

Do you own or rent this location? *

Own
Rent

How much business contents coverage do you need? (inventory, furniture, computers, etc.) *

Does your business location have any of the following? *

Central burglar alarm
Central fire alarm
Sprinklers
None

Do you have more than one location? *

How many properties do you own / manage? *

Additional Location

Address *

Address Line 1

City

State

Zip Code

Do you own or rent this location? *

Own
Rent

Approximately how many square feet does your business occupy? *

How much business contents coverage do you need? (inventory, furniture, computers, etc.) *

Does your business have any vehicles? *

Vehicle

Year *

Make *

Model *

VIN *

Driver

Name *

Date of Birth *

License Number *

License State *

You're almost done!

Great job! you've completed your application. Now is your chance to give us any last-minute details that will help us provide the best quote for you. Are there special circumstances we should take into account? Are you not sure if you answered a question correctly? Let us know!

Additional Remarks: