Commercial Insurance Form
APPLICANT INFORMATION
Please fill in all fields for an accurate quote
APPLICANT/NAMED-INSURED:
DBA:
LOCATION ADDRESS:
CITY/STATE/ZIP:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illlinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
COUNTY:
E-MAIL:
Change Mailing Address if different from Location Address
MAILING ADDRESS:
MAILING ADDRESS:
CITY/STATE/ZIP:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illlinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
COUNTY:
PHONE NUMBER:
INSPECTION CONTACT & CONTACT NUMBER:
ACCOUNTING CONTACT & CONTACT NUMBER:
CLAIMS CONTACT & CONTACT NUMBER:
TAXPAYER ID & SSN:
NUMBER OF OWNERS/EXECS:
BUSINESS TYPE:
Corporation
Individual
Partnership
LLC
NUMBER OF YEARS IN BUSINESS:
BUSINESS DESCRIPTION:
Description must exceed 10 words.
Copyright 2011 Ben Miller Insurance, Lic# 0E14637