Home Business Insurance Quote

Business Insurance Quote

Please fill out as much information as possible.
If you have any questions regarding this form please contact us.
–TEXAS RESIDENTS ONLY–

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured

Full Name (required):
DBA (required):
Phone (required): Cell: Fax:
Website Address: # of Locations:
Email (required): (EIA use only)
Mailing Address:
City: State: Zip Code:

Coverage Information

Nature/Type of Business:
Business Model:
Type of Coverage: Commercial Auto Commercial Property General Liability Business Personal Property Workers Comp Umbrella Other
Current Carrier: Expire Date:
Business Address:
City: State: Zip Code:

Business Information

Years in Business: Number of Employees:
Full-time: Part-time:
Annual Payroll: Annual Gross Sales: # of Bus. Owned Vehicles:
Any Business use of employee owned vehicles: If Yes, how many?
* If yes, please supply details below in Comments/Remarks section

Loss Information

Have you ever had any losses in the last three years? Describe:

Other Locations

List any other locations you have:

Other Comments/Remarks

Please enter the following:

Submission of quote request form to Ellis Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or policy revision you must receive verbal or written confirmation from a licensed E.I.A. representative.