United Infrared Member Quotes
Company Name:
*
Contact Name:
*
First
Last
Phone
*
Website
Effective Dates:
*
Commercial Type:
*
Corporation
LLC
Individual
Other
Requesting Quote for:
*
Property/GL
Commercial Auto
Inland Marine
Workers Comp
Professional
Commercial Type:
If Other what is your Commercial Type?
NOTE: Explanation of all coverages offered here can be found under the business insurance tab.
Tax ID#
*
Years in business:
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County:
*
Construction type of building:
*
Estimated year built:
*
Sq Footage:
*
Description of business:
General Liability
1 mil / 2 mil
2 mil / 4 mi
Auto Liability for company owned vehicles
1 million CSL
Other
Professional Liability
500,000
1 million
2 million
Workers Comp
100/500/100
500/500/500
1 mil /1 mil /1mil
Umbrella
1 million
2 million
Other
Building Coverage Needed?:
*
Contents Coverage Needed?
*
Equipment Coverage Needed? (camera, specialty testing equipment etc.)
Value of equipment
Auto
VIN
Value
Driver Name
DL#
DOB
MM slash DD slash YYYY
Upload loss runs or copy of current policy
Max. file size: 59 MB.
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November 20th, 2015
by
Hartsfield and Nash Insurance Agency, Inc.