Simmons Insurance Agency -- Business Quote Form

CARRIER

POLICY #

PREMIUM PAID

# CLAIMS

LOSSES PAID $

OPEN RESERVE $

HOME ABOUT THE AGENCY SERVICES CONTACT US DICTIONARY PRIVACY POLICY

Thank you for your interest in a Free Quote from Simmons Insurance Agency. This form will take you approximately 5 minutes to fill out. A quote, based on the information you have provided, will be returned to you within one week.

Premiums are subject to change and policy acceptance is subject to underwriting guidelines. This is not a firm quote nor is this an insurance policy.

BUSINESS QUOTE


NAME OF COMPANY:
CONTACT PERSON:
PHONE NUMBER:
FAX NUMBER:
ADDRESS:
CITY:
STATE:
ZIP:
TYPE:
IF OTHER:

OFFICERS OR OWNERS

TITLE	DOB	SSN	%OWN

If additional Officers and/or Owners please in comments below

DESCRIPTION OF OPERATIONS

TYPE OF COVERAGE REQUESTED

	WORKERS COMPENSATION		COMPREHENSIVE GENERAL LIABILITY
	PROPERTY		COMMERCIAL AUTO
	PROFESSIONAL		DIRECTOR AND OFFICERS
	ERRORS AND OMISSIONS		UMBRELLA
	CONTRACTORS RISK		BONDS
	CRIME/THEFT		EMPLOYEE DISHONESTY
	GROUP HEALTH		DON'T KNOW

If you selected "don't know" or would otherwise like to be contacted, please tell us how
By: at:

COVERAGE QUESTIONS (please provide detail for any YES answer in the comments section below)

Question	YES	NO
1. DOES THE APPLICANT OWN, OPERATE OR LEASE ANY AIRPLANES/WATERCRAFT?
2. ANY PAST, PRESENT OR DISCONTINUED OPERATIONS WHICH INVOLVE EXPOSURE TO CHEMICALS, PAINT OR HAZARDOUS MATERIALS?
3. ANY WORK PERFORMED UNDER, ON OR ABOVE WATER?
4. ANY WORK PERFORMED UNDERGROUND OR HIGHER THAN 15 FEET ABOVE GROUND LEVEL?
5. ANY WORK WHICH MAY BE SUBJECT TO THE JONES ACT, USL & H OR FELA?
6. IS APPLICANT INVOLVED IN ANY BUSINESS OPERATIONS OTHER THAN THAT SPECIFIED IN THE "DESCRIPTION OF OPERATIONS"?
7. ARE ANY OF YOUR EMPLOYEES LEASED?
8. ARE ANY OF YOUR EMPLOYEES TEMPORARY?
9. ARE ANY OF YOUR EMPLOYEES SEASONAL?
10. ARE ANY OF YOUR EMPLOYEES VOLUNTEER OR DONATED LABOR?
11. ARE ANY EMPLOYEES UNDER THE AGE OF 16 YEARS?
12. ARE ANY EMPLOYEES OVER THE AGE OF 60 YEARS?
13. DO ANY OF YOUR EMPLOYEES TRAVEL OUTSIDE THE STATE OF COUNTRY?
14. DO YOU SPONSOR ANY ATHLETIC TEAMS?
15. DO YOU PROVIDE ANY GROUP TRAVEL, RIDE-SHARE PROGRAMS, TOOL OR VEHICLE ALLOWANCES?
16. DO YOU REQUIRE EMPLOYEES TO COMPLETE A PHYSICAL AFTER OFFERS OF EMPLOYMENT ARE MADE?
17. DOES THE RADIUS OF THE OPERATION OF ANY OF YOUR VEHICLES EXCEED 200 MILES?
18. DO YOU CHECK MVR'S ON ALL DRIVERS OPERATING COMPANY VEHICLES?
19. DO YOU HAVE A WRITTEN SAFETY PROGRAM THAT YOUR EMPLOYEES ARE TRAINED FOR AND FOLLOW?
20. DO YOU HAVE A DRUG TESTING POLICY AND PROGRAM IN PLACE?
21. DO YOU HAVE AN EARLY RETURN TO WORK PROGRAM IN PLACE FOR INJURED EMPLOYEES?
22. DO YOU PROVIDE HEALTH, HOSPITAL AND MEDICAL COVERAGE FOR YOUR EMPLOYEES?
23. DO YOU USE ANY SUBCONTRACTORS?
24. ARE THEIR EMPLOYEES INSURED FOR WORKERS' COMPENSATION?
25. DO YOU KEEP COPIES OF THEIR CERTIFICATES OF INSURANCE?
26. HAS ANY PRIOR COVERAGE BEEN DECLINED, CANCELED OR NON-RENEWED IN THE PAST THREE (3) YEARS?

IF APPLYING FOR WORKERS COMPENSATION, PLEASE COMPLETE THE FOLLOWING, OTHERWISE SKIP

WORKERS' COMPENSATION INSURANCE POLICY HISTORY:

EMPLOYERS LIABILITY COVERAGE AMOUNT REQUESTED
$100,000/$100,000/$300,000
$500,000/$500,000/$500,00
$1,000,000/$1,000,000/$1,000,000