COMMERCIAL QUOTE QUESTIONNAIRE:

PLEASE FILL AND SUBMIT THE FORM BELOW FOR A FREE-NO OBLIGATION QUOTE FOR COMMERCIAL INSURANCE NEEDS:

PLEASE REMEMBER...........NORTH CAROLINA HEADQUARTERS ONLY!:

Please provide the following contact information:

Name
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Work Phone
Home Phone
FAX
E-mail

BUSINESS APPLICATION AND DETAILED DATA:

Indicate general nature and type of business (Please be detailed)

Business Name

Start Date

Years in Business

Type of Ownership

What type of insurance do you need?

Explain type of Property:

Building Insurance
Explain:

Business Personal Property
Explain:

Glass & Signs		Please Explain
Crime		Please Explain
Equipment Floater		Please Explain
Electronic Data		Please Explain
Builders Risk		Please Explain
General Liability		Please Explain
Business Auto		Please Explain
Vehicle Schedule		Please Explain
Truckers		Please Explain
Boiler & Machinery		Please Explain
Workers Compensation		Please Explain
Umbrella		Please Explain
Other		Please Explain

PLEASE TELL US WHO YOU ARE INSURED WITH NOW
PLEASE TELL US HOW YOU HEARD ABOUT CAROLINA INSURANCE
IF YOU SELECT OTHER PLEASE TELL US WHERE
PLEASE SEND MY QUOTE BY

Please note due to the varying degree of coverage's available under the commercial programs it may be necessary to email or contact you for additional information depending on your individual business needs.

Thank you for your quote submission.

***PLEASE NOTE: COMPLETION OF THIS FORM IN NO WAY IMPLIES THAT YOU HAVE INSURANCE COVERAGE.