Auto Insurance Quote Request


For the fastest and most accurate business insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only. Please note that no coverages can be bound through this form.

Thank You!

Business Information
Business Name:
Address:
City: State:    ZIP:
Contact Name:
Phone:              fax:
Email:  

Business Type:

 Corporation Partnership Individual
Business Description:
Years in Business:
Present Insurance
Company (not agency):
Policy Exp. Date:
Expiring Premiums
Last 3 Years:		 / /

 

Property Information
Location Address:
City: State:    ZIP:
Type of Construction: Frame
Masonry (block wall - wood roof)
Non-combustible (block wall-metal roof)
Sprinklered:   Yes No
Alarm:   Burglar Fire
Type of Alarm: Local Central None
Occupied By: Owner Tenant
Glass Linear Feet: Sign Value:
Building Value : Age of Building:
Deductible: Business Contents:
Tenant Improvements:
Computer Hardware: Software:

 

Liability
Liability Limit :   $500,000 $1,000,000
Number of Employees: :   Full Time Part Time
Annual Payroll: Employees Owners
Gross Sales Non-food: Food: Liquor:
Number of Claims: Payout Amount:

 

Automobile
Liability Limit :   $500,000 $1,000,000
Year
Make
Model
Comprehensive
Deductible
Collision
Deductible
Cost New
GVW
Number of Claims: Payout Amount:

 

Workers Compensation
Class Code
Number of Employees
Payroll
Number of Claims: Payout Amount:

Thank you for your time in submitting this online quote form. One of our representatives will respond to your submission as soon as possible! Please take note that no coverage is bound by this quote form. All quotes are estimates based on the information provided.

 

203 CHURCH ROAD | MEDFORD, NJ  08055-9512
PHONE: (609) 654-5105 | FAX: (609) 654-7975
EMAIL: dmiller@meyer-insurance.com