Business Insurance Quotation

from Fitzwilliam Insurance Services, LLC

Please complete this one page
Business Insurance Quotation Request Form.
Click here for Frequently asked Questions

General Information

Contact Name

 

E-Mail

 

Business Name

 

Address

 

City

 

State

Louisiana

 

Zip Code

 

Parish

 

Business Phone

 

Fax

Current Insurance Company (not agency)

Company Name

 

Current Expiration Date

 

Current Insurance Coverages

Bond

 

Commercial Auto

 

Commercial Liability

 

Commercial Property

 

Commercial Umbrella

 

Directors and Officers Liability

 

Disability

 

Group Health

 

Group Life

 

Professional Liability

 

Workers' Compensation

 

Other

Business Information

# of Full-Time Employees

 

# of Part-Time Employees

 

How long in Business? (yrs)

 

How many locations?

 

Please give a brief description of your business and clientele.

Property/Premises Information

Address

 

Occupancy Status

Owner

Tenant

 

Year Built

 

% Occupied

 

Sprinklers

Yes

No

 

Construction Type

 

# Stories

 

# Basements

 

Square Footage

 

Burgular Alarm

Yes

No

 

Building Value

 

Contents

 

Other Property (specify)

Insurance Information

Other

 

Annual Gross Sales: (before taxes)

 

Number of Employees

 

Annualized Payroll

 

Cost of any Subcontracted Work

 

Limits Requested

$300,000

 

$500,000

 

$1,000,000

 

$2,000,000

 

Describe any claims you've had in the past 5 years

 

Additional Comments

 

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3112 Williams Blvd.
Kenner, Louisiana 70065
Phone: 504-469-9416

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