Commercial Insurance, Hierl Insurance

Commercial Package Quote Request Form

Fill out the form below or
download the PDF version of the Commercial Package Quote Request form.

General Information

Name of Business
Contact Name
Address
City
State
Zip
Email
Business Phone
Fax

Current Insurance Company (not agency)

Company Name
Policy Exp.

Current Coverages

Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Worker's Compensation
Other:

About Your Business

	Number of full time employeess
	Number of part time employees
	How long in business (years)
	How many locations
	Annual Sales (in dollars)

Please give a brief description of your business and clientel.

Property/Premises Information 1

Street Address
	Owner Tenant
Year Built
% Occupied
Sprinklers?	Yes No
Construction Type
# of Stories
# of Basements
Square Footage
Burglar Alarm	Yes No
Building Value	$
Content Value	$
Other Property (specify)

Property/Premises Information 2

Street Address
	Owner Tenant
Year Built
% Occupied
Sprinklers?	Yes No
Construction Type
# of Stories
# of Basements
Square Footage
Burglar Alarm	Yes No
Building Value	$
Content Value	$
Other Property (specify)

Property/Premises Information 3

Street Address
	Owner Tenant
Year Built
% Occupied
Sprinklers?	Yes No
Construction Type
# of Stories
# of Basements
Square Footage
Burglar Alarm	Yes No
Building Value	$
Content Value	$
Other Property (specify)

Business Information

Class of Business
Other
Annual Gross Sales (before taxes)	$
Number of Employees
Annualized Payroll	$
Cost of any Subcontracted Work	$
Limits Requested	$300,000 $500,000 $1,000,000 $2,000,000
Describe any claims you've had in the past 5 years.

Additional Comments Please give any additional comments about the coverage you desire.

Fond du Lac Office: 258 S. Main St., POB 949, Fond du Lac, WI 54935, Ph: 920-921-5921, Fax: 920-921-6239
Appleton Office: POB 2815, Appleton, WI 54911, Ph: 920-993-9573, Fax: 920-993-9869