Business Quote Form - Benfield Insurance Agency

How did you find our agency?*

Social Media

Customer Referral

Google Search

Google Ad

Bond

Commercial Auto

Commercial Liability

Commercial Property

Liquor Liability

Directors & Officers Liability

Disability

Group Health

Group Life

Professional Liability

Workers' Compensation

Other

# of Full-Time Employees

# of Part-Time Employees

How long in Business? (yrs)

Please give a brief description of your business and clientele

Occupancy Status
Owner Tenant

Burglar Alarm
Yes No

Other Property (specify)

Business Personal Property Amount

Annual Gross Sales: (before taxes)

If Liquor Liability Required-Gross Annual Liquor Sales?

Cost of any Subcontracted Work

Liability Limits Requested

$300,000

$500,000

$1,000,000

$2,000,000

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

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