Specific Insurance Quotes

Phone: (888) 347-2648

Email: quotes@graniteins.com

 

* Please fax or email all quotes to quotes@graniteins.com. We will contact your client within 24 hours with a quote or additional information.

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  1. Please provide as much information as possible to assure the most accurate quotes. Leave blank if you are not sure of an answer.
  2. GENERAL INFORMATION
  3. Name of Business(*)
    Please type your Name of Business.
  4. Name of Owners OR Officers
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  5. Contact Name(*)
    Contact Name
  6. Contact Phone(*)
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  7. Mobile Phone(*)
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  8. Contact E-mail(*)
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  9. Address
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  10. City
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  11. State
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  12. Zip
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  13. Business Info(*)
    Please tell us how big your company is.
  14. Years in Business
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  15. Fed Tax ID Number
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    Cannot quote without.
  16. Business Description
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  17. REFERRING REPRESENTATIVE INFO.
  18. Payroll Company Name
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  19. Phone
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  20. Fax
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  21. Email
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  22. POLICY INFORMATION
  23. Current Insurance Company
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  24. Annual Premium
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  25. Policy Period:
  26. Effective Date
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  27. Expiration Date
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  28. Work Comp Modifier
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    If known.
  29. Will Officers be Included or Excluded- Please Explain
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  30. Additional Officer Info:
    List Owner(s) Names, Dates, & Percentage of Ownership. (Percetagess Must Total 100%)
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  31. Any Other Carriers
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  32. If Yes, Please List Name(s) & Estimated Premium:
    (last 3 years)
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  33. Any Insurance Claims Filed
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  34. If Yes, Please Give the Fallowing Data: Date of claims, amount of claims, description, & cost of claims.
    (last 3 years)
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  35. PAYROLL & CLASS CODE INFORMATION

    36. Class Code
    or Job
    Description:
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    (B)
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    (C)
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    (D)
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    (E)
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    Number
    of F-T
    Employees:
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    (B)
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    (C)
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    (D)
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    (E)
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    Number
    of P-T
    Employees:
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    (B)
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    (C)
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    (D)
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    (E)
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    Estimated Annual
    Payroll
    Per Class Code:
    $ Invalid Input
    (B)
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    (C)
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    (D)
    $ Invalid Input
    (E)
    $ Invalid Input

  36. Additional Locations
    (Please List)
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  37. Do You Require Coverage Above Mandatory Limits?
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  38. If Yes, Please Describe Required Limits
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  39. Do You Work Outside of Your State
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  40. Additional Comments & Information
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  41. Attach Files
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  42. Files#1
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  43. Files#2
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  44. Please click the "Submit Quote Request" button to send your quote request. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.
  45.