Business Quote

Business Insurance Quote Request Form

NOTE: The following request does not guarantee coverage or a coverage change. H. B. Cantrell and Co. is licensed to quote and write insurance policies only in North and South Carolina. Fill out this form and submit it to us to receive an accurate business insurance quote. An H. B. Cantrell and Co. staff member will confirm any changes and inform you of the effective date and time of your change. All information will be kept strictly confidential. It is important that all information be completely filled out.

Owner's Name:

Nature Of Business/Description Of Operations:

Business Legal Entity:

Sole Proprietor

Partnership

Corporation

Other

DBA:

Day Phone:

Night Phone:

Fax Phone:

Best Time To Call:

E-Mail Address:

Mailing Address:

City:

State

Zip

Property Address:

City:

State

Zip

Own Or Lease Property?

Own

Lease

If Own, Type Of Bldg. And Date Purchased:

List Number And Type Of Occupants In Building:

Type of Construction:

No. Of Sq. Ft. Occupied:

Year Built:

No. Of Units To Be Insured:

Percentage Of Building Has Sprinklers:

Type Of Parking Available:

Type Of Security:

Does Property Have A Pool:

Building Improvements And Dates:

Present Insurance Co.:

Building Amount:

Building Contents Amount:

Loss Of Income Amount:

Deductible:

Liability Amount:

Misc. Coverages And Amounts:

Renewal Date:

Current Company:

Give Brief Description Of Any Losses In The Last Five Years:

Other Pertinent Information You Feel Would Be Important To Your Quote:

I Am Interested In More Information Regarding The Following Coverages:

Auto	Life	Annuities	Health
Disability Income	Long Term Care	Home	IRA
Boat	Apartment