COMMERCIAL INSURANCE
QUOTE REQUEST
(Liability / Property / Package / Umbella)

We at Hudson & Muma believe that it is important to offer our customers the most up-to-date technology available which will enhance the service they receive. It is because of this commitment that we are offering this form to aid in generating accurate applications and forms quickly and efficiently!

Remember, without complete information, we may be delayed in producing your quote, so please complete ALL applicable fields.

SUBMITTING THIS FORM YOU ARE AGREEING TO THE CONDITION THAT NO MATERIAL CHANGE WILL BE MADE TO YOUR POLICY UNLESS AND UNTIL YOU RECEIVE CONFIRMATION OF THAT CHANGE FROM A HUDSON & MUMA ASSOCIATE OR AN ASSOCIATE THAT THE INSURANCE COMPANY WRITING THE COVERAGE.
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    COMMERCIAL QUOTE REQUEST

    Please check the lines of insurance that you would like us to quote for you:

    PropertyGeneral LiabilityUmbrella
    (Workers' Compensation and Auto are on separate forms)

     

     

    Insured Information

    Insured or Company Name*:


    Your Name*:
    Phone Number*:
    Your Email*:
    Fax Number:
    Web Site:
    Policy Number(if applicable):

     

     

    Years In Business:


    Industry Type:
    If Other, describe:

    Describe your business operations:


    Number of Employees:

     

     

    Quote Effective Date:

    List Current Insurance and Insurance Companies:

     

     

    PRIMARY LOCATION

    Do you own or lease this location:

    OwnLease
    Complete Locaiton Address:

    If you Own, or are responsible for insuring this building location, what is the Replacement Value:


    What is the total value of your Business Personal Property?(e.g. furniture,fixtures, equipment, machinery, stock, etc.):
    What is the sq. footage of the space you occupy?:

    What is the sq. footage of the entire building?:
    Type of Construction:

    Alarm Type?:

    NoneCentral BurglarCentral FireCentral Burglar and FireLocal BurglarLocal FireLocal Burglar and Fire
    Is Location Sprinklered?:YesNo
    Number of Stories:
    Year building was built:
    If older than 30 years, describe updates/renovations and approximate dates (please include Roof/HVAC/Plumbing/Electrical):

    Describe any losses you have experienced at this location in the last 5 year. Include description and amounts paid:

     

     

    LOCATION 2: Do you own or lease this location:

    OwnLease
    Complete Locaiton Address:
    If you Own, or are responsible for insuring this locaiton, what is the Replacement Value:
    What is the total value of your Business Personal Property?(e.g. furniture,fixtures, equipment, machinery, stock, etc.):
    What is the sq. footage of the space you occupy?:
    What is the sq. footage of the entire building?:
    Type of Construction:
    Alarm Type?:NoneCentral BurglarCentral FireCentral Burglar and FireLocal BurglarLocal FireLocal Burglar and Fire
    Is Location Sprinklered?:YesNo
    Number of Stories:
    Year building was built:
    If older than 30 years, describe updates/renovations and approximate dates (please include Roof/HVAC/Plumbing/Electrical):

    Describe any losses you have experienced at this location in the last 5 year. Include description and amounts paid:

     

     

    If you have more than two locations, please contact us or fill in another form.

     

     

    General Liability

    General Liability Limits:


    If Other, specify:

     

     

    Your Estimated Annual revenue:


    Your Estimated Annual Payroll:
    What Percentage of your sales are from Internet:

     

     

    Umbrella limit desired:

    None1,000,0002,000,0003,000,0004,000,0005,000,000

     

     

    If your application is complete, please click the Submit button below. Once submitted, your information will be automatically transmitted and you will be contacted by a Customer Service Representative within one business day.

     

     

    NOTES:

    Referred By:

    Who Writes Your Life/Health Insurance:

     

    Attachments:

    If you have any applicable documents, photos, lease copies or others, please attach here.



    Name of person completing form:*

    Confirmation Email Address:*

    (We need this to send you a confirmation receipt for this form.)