Kleinschmidt Insurance—Business Insurance Quote Request

QUOTE FORMS

CLAIMS

Please complete this form as completely and accurately as possible and submit it to us when you are finished. If you wish, you may also print out the form and fax it to us (734•662•5370) or call our office with this information.

Note that we cannot provide coverage until a policy or binder has been issued by the insurance company. As part of our quoting process, we may need to verify some information such as credit history, prior insurance history, and financial stability information.

Contact Information
Name of business:
Contact name:
Street address:
City:
State:
Zip code:
County:
Business phone:
Fax:
Email address:
Current Insurance Company (not agency)
Company name:
Policy expiration date:
Current Coverage
Bond	Disability
Commercial Auto	Group Health
Commercial Liability	Group Life
Commercial Insurance	Professional Liability
Commercial Umbrella	Workers Compensation
Commercial Umbrella	Liqour Liability
Directors and Officers Liability	Other
About Your Business
Number of full-time employees:
Number of part-time employees:
How long in business:
How many locations:
Annual sales:
Please give a brief description of your business and clientele:
Desired Coverage
Bond	Disability
Commercial Auto	Group Health
Commercial Liability	Group Life
Commercial Property	Professional Liability
Commercial Umbrella	Workers Compensation
Directors and Officers Liability	Other