JOHNSON & BRYAN - Insurance Brokerage and Risk Management

Commercial Coverage Quotation Request

New businesses need answers quickly with cost effective solutions. Johnson & Bryan has a department dedicated to address your needs. Please answer as much of the requested information and submit for a premium indication.

Note: BOLD indicates required field

Name:
Your Company:
Address:
City:	State: Zip:
Business Phone:	Fax:
E-mail:

Types of Coverage Needed (check all that apply)
Auto	Liability	Inland Marine/Tools & Equipment
Bonds	Workers' Comp	Builders Risk
Property	Professional Liability	Other

Pay Plan Desired

Business Information

Years in Business:
Number of Employees:
Number of Locations:
Annual Sales:
Description of your operation:

Property Coverage

Building Location:	Same as above
Address:
Building Amount:
Square Feet:
Building Age:
Construction:
Automatic Sprinklers:
Contents Value:
Computer:
Inventory:
Desired Deductible:

Workers' Compensation

Classification or description of work performed:
Number of Employees:
Payroll:
Federal ID or SS#:
List Owner:
Include Owner for W/C?

Automobile Information

Liability Limit:
Comprehensive Deductible:
Collision deductible:
Vehicle Year:
Make:
Model:
Garage at City:
Zip Code:
Cost New:
Driver's Name:
Date of Birth:
License Number:

Additional Comments

Additional Comments / Requests / Interest

NOTE: This is Johnson & Bryan general information and I am under no obligation to accept coverage. I realize this does not bind coverage.