For a free Business Insurance Quote, please complete the below.  
Your name:
Your email address:
Your phone number:
Company Name:
Company Established
Provide a brief description of  what your company does
by percentage(%).  For example, we provide IT
Consulting (50%), MSP (30%) and VAR Services (20%)
Confirm Total Revenues

Most Recent Financial Year:

Project for Next Financial Year:
Your Building Info:

Does Your business own the building?   
Click if yes.

Does your business rent / lease office
space?  Click if yes.

Is your office located in your home?

What is the value of the business
property to be insured?   (include
computers, furniture, phones, faxes etc.
in $ amount per location)

What is the value of the building if owned
by the business?

Construction Type:
1.  Wood / Frame
2.  Brick / Stucco - Joisted Masonry
3.  Masonry Noncombustible -
4.  Reinforced Steel

What year was the office / building built?   

How many floors is the building?

What is the Total Square Footage of the
part you occupy?

Sprinklered?   Check if yes

Does building have (central station or
other type of) burglar alarm?

Same as mailing address above
Location address(es) if different than
mailing address noted above:

If you have more locations add in
comment section.
Location Address #1:
Location Address #2:
Employee Info:

Total number of Staff:

Total Payroll:  

Workers Comp:   (Optional)

Federal Employer Identification Number
(FEIN #)

Number of employees at each location:

Annual Payroll by employee class type is

8810- Clerical / Admin

8809 - Executive Management

8810 - Computer tech in office

8803 - Computer Tech - Travels

5191- Computer repair / installation

Other:  please clarify what person(s) do
and their total annual payroll:

Yes                               no
Claims Experience:
Have you had a claim or been declined, cancelled or
non-renewed during the past three years?  
How Did You Hear About Us?
Additional Comments /
Thoughts or Needs?
If you can insert an auto signature, do so here,
 If not, print your name.  Some underwriters
may require signed application upon binding.  
I hereby declare that I am authorized to complete this application on behalf of the applicant and that after
due inquiry, to the best of my knowledge and belief, the statements and particulars are true and complete
and no material faces have been misstated, suppressed or omitted.  I undertake to inform underwriters or
addition to these statements or particulars which occur before or during any contract of insurance based
on the applications is effected.  I also acknowledge that this application (together with any information
supplied to underwriters) shall be the basis of contract.

I understand that underwriters will rely on the statements that I make on this form.  In this context, any
insurance coverage that may be issued based upon this form will be void if the form contains falsehoods,
misrepresentations or omissions.   
Click here to submit and agree to this declaration.
Telephone:  267-803-1371
Toll:   866-355-Risk   (7475)    
Fax:   267-371-5188

office located at: 5788 York Road, Lahaska (Buckingham Twp), PA 18931