Business Insurance Quote Request

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We promise to respond quickly to your request.
To receive an business insurance quote,
complete the below form.
If you prefer, fax a copy of your policy to 508-347-5798.
Or you can call us at 508-347-9343
during business hours if that's more convenient.

Business Insurance Information
	Business Contact
Number
Name
Business Name
Address 1
Address 2
City/State/Zip	/ /
Phone
Cell
Date of Birth
Email

Preferred Contact Method
Email Phone	AM PM
Business Insurance Needs
Property
Equipment
Liability
Automotive
Workers Compensation
Other
Type of Business
Contractor
Retail
Service
Condominium Owner
Apartments
Office
Wholesale
Please Describe your Business Operation
Number of years experience:*
How long in business:*
Number of owners, partners or officers
Number of full-time employees:
Number of part-time employees:
Number of contract employees:
Annual receipts:
Annual payroll:
Property Information
Address1
Address2
City/State/Zip	/ /
Business occupancy:
Construction type:
Value of building (if owned):
Value of contents:
Value of tools and equipment:
Prior Insurance Coverage
Has this business been previously insured?	Yes No
If yes, how many years?
When does the current policy expire?

Loss History
Please specify all losses related to this business operation and/or business property. Be sure to include the date the loss occurred, a description, and the loss amount. If the business has no losses, please check the circle below.	no loss history
Comments
Please provide any additional information that will help us to provide you with the most accurate quote possible.
Privacy and Security
McCurdy Group takes seriously the protection of information you share with us. Law regulates the collection, use and disclosure of such information. For additional details, please review our privacy policy, online security information and terms & conditions. I have read the privacy policy and terms & conditions and want to continue. Please Note: Insurance coverage cannot be bound without a written binder from our office.