Commercial Quote Questionnaire

Today's Date
Date Format: MM slash DD slash YYYY
Effective Date of Policy
Date Format: MM slash DD slash YYYY
Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Legal Business Name
FEIN#
'Doing Business as' Name (DBA)
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone
Details of Business Operations
Please let us know who, if so, you have been working with at Fox Insurance:
Do you have current Insurance in place?
If so, who is your current Insurance Carrier?
Have you had any losses in the last 5 years?
Does your business own any buildings?
Does your business rent any buildings?
Does your business own any commercial vehicles?
How many employees do you have not including owners?
Which method of communication do you prefer for one of our agents to reach out to you?