Ellis Insurance Agency, Serving San Antonio and Texas

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If you have any questions regarding this form please contact us.

Business Quote Request Form - (Texas Residents Only!)

(* Indicates a required field)

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

Named Insured:

Coverage Info:

*Full Name:

Nature/Type of Business:

* dba:

Business Model:

*Contact Phone:

Cell #

Commercial Auto:

General Liability:

Fax:

Commercial Property:

Business Personal Property:

Web URL:

# of Locations:

*see below

Workers Comp: Umbrella: Other:

*Email: (EIA use only)

Current Carrier: Expire Date:

*Mailing Address:
Address: City:

State: Zip: County:

Business Address: Same as Mailing Address

Add: City:

State: Zip: County:

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 had any losses in the last three years? Describe:

Other Locations:

List other locations you have:

Comments/Remarks:

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.