Association Insurance Programs - IT / Technology Quote

IT / Technology Business Insurance Quote Request

Thank you for completing the quote request form. We will be in contact with you as soon as possible.

Contact Name:
BusinessName:
Address:
City:
State:
Zip / Postal Code:
Country (if not USA):
Phone:
Email Address:
Website:
Tax ID:
Business Entity Type:
Currently Insured?
If yes name of carrier:
Date coverage needed:
Years of industry experience:
Year business started:
Description of business operations:
Total Receipts:
Total payroll:
Amount of Subcontracted work:
If using Subcontractors do you require and keep copies of their insurance coverage on file?
Any Claims or Losses against the business in the last 5 years?
If Yes Please Describe:
Liability Limits desired:
Do you want a quote for Technology Errors & Ommissions coverage?
Do you lease or own the space your office is in?
If owned please list the replacement cost value:
Type of construction:
If other please describe:
Year built:
Alarm System:
Sprinkler System:
Smoke Detectors:
Value of your office equipment:
Value of the stock / inventory:
Do you use tools away from your office?
If yes what is the total value of your tools?
Do you have vehicles titled to or leased in the name of your company to be insured?
If yes list make model VIN # Deductible:
Workers Compensation:
Number of employees & total payroll:
Number of owners / officers & total payroll:

Comments:
Business Life Insurance?
Amount?
Cash Value / Asset Value?
Do not enter anything in this field: