Safe Harbour Insurance
40 Industrial Park Rd. Suite 301
Plymouth, MA 02360
800-508-7311 toll free
508-746-7990 voice
508-746-7991 fax

Business Insurance Quote Request

1. Company Name

2. Address

3. City
 State
 Zip

4. Email

5. Contact Person:

6. Area Code and Office Phone / Ext:

7. Area Code and FAX Phone:

General Information

8. Effective date of coverage

9. Full description of your business (This will help us identify your insurance needs)

9a. Describe your business

9b. List year business was established

10. Is this a seasonal business? Yes No
11. Do you currently have business insurance? Yes No

12. If insured, name company insured with

13. Choose which type of business insurance you would like a quote on

14. Annual Gross Receipts

15. Total Annual Payroll

16. How Many Employees

17. Have you had any insurance claims in the last three years? Yes No
17a. If yes, please describe and list amount of claim settlement.
18. Do you own your company's building? (Not applicable if you work out of your home) Yes No
18a. If yes, state building replacement value $

19. Deductible (choose one)

20. Are you the only occupant in your building? Yes No
20a. If no, describe other tenants (i.e. restaurant, retail etc.)
21. If you are a tenant, are you required to insure the building? Yes No
21a. If yes, Sstate replacement value $

22. List building address if different than mail address / City / Zip

23. Age of Building

24. Building Construction

25. Is Building Alarmed? Yes No
25a. If yes,
a. Burgler Alarm Yes No
b. Smoke Alarm Yes No
c. Central Station Yes No
26. Sprinkler System in building? Yes No

27. Business Personal Property (Contents) State Replacement Value $

28. Deductible (choose one)

29. Commercial General Liability (choose one)

30. If you are a contractor, list value of tools & equipment (exclude vehicles) $

31. Computers? Yes No
31a. If yes, replacement value $
32. Signs? Yes No
32a. If yes, state replacement value $

33. Questions / Comments

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Important Note: Quotes will be based on the information provided. It is only a rate calculation and is not binding in any way. A full application must be completed and signed by the named insured.