Business & Commercial Quote | Jaikar Insurance Services

1 Business Name, Address & Type?

Business Name Business Address, City, ZIP Type of Business / What do you do? (e.g. Contractor, Restaurant, Shop)

Years in Business

Entity

LLC Corp Sole Prop Partnership

Number of Employees (including yourself) Estimated Annual Payroll $

Estimated Annual Gross Sales / Revenue $

Do you Own or Rent?

Own Rent

If Own — Building Value $ / If Rent — Monthly Rent $

Current Insurance Company & Premium

Any Claims / Cancellation Last 3 Years?

Yes No

Explain

Select coverages

General Liability Workers Comp Property Tools / Equipment Commercial Auto

Standard $1M / $2M or contract requires: $ Does any contract / license require special limits?

Do you use Sub-Contractors?

Yes No

Are they insured with COI?

Yes No

Effective Date Needed

Need COI Today for Job / License?

Yes No

Name (Required) Phone (Required)

Email (Required)