Commercial Insurance Quote — Wayne Lilly Insurance

1

Business Information

Required

Business legal name *

DBA / Trade name

Business address *

Mailing address (if different)

Business phone *

Business email *

Website

FEIN / Tax ID

Type of business entity

Year established

Industry / type of business *

Business description *

Full-time employees

Part-time employees

Annual gross revenue

Primary contact name *

Contact title

2

Coverage Selection

Choose one or more

Which coverage(s) would you like a quote for? *

General Liability Bodily injury, property damage, advertising injury

›

Commercial Property Building, contents, business income, equipment breakdown

›

Commercial Auto Company vehicles, hired & non-owned auto

›

Requested coverage start date *

Are you currently insured?

Yes No

Current insurance provider

Current premium

Policy expiration / renewal date

Upload current declarations page

Helps us provide an accurate apples-to-apples comparison and identify coverage gaps.

3

General Liability

Section unlocked

Coverage preferences

Preferred coverage limit

Preferred deductible

Do you require Additional Insured endorsements?

Yes No

Names and relationships of Additional Insured parties

Are specific contracts or clients requiring this insurance?

Yes No

Please provide details

Business location & operations

Do you own or lease your premises?

Own Lease Home-based No fixed location

Number of locations

Square footage of primary premises

Additional location addresses and square footage

Are hazardous materials used or stored on-site?

Yes No

Describe hazardous materials

Do you perform work outside your primary location?

Yes No

Describe work performed off-site

Work outside your primary county in Texas?

Yes No

Work performed outside of Texas?

Yes No

Do you work with subcontractors?

Yes No

Do subcontractors carry their own GL insurance?

Yes No Some do

Approximate annual amount paid to subcontractors

Approximate percentage of work by type

Residential %

Commercial %

Industrial %

Claims history

Any GL claims in the past 5 years?

Yes No

Claim details — include dates, type, and amount paid

4

Commercial Property

Section unlocked

Property details

Property address (if different from business address)

Do you own or lease the building?

Own Lease

Year built

Total square footage

Construction type

Number of stories

Roof type

Year roof last replaced

Sprinkler system?

Yes No

Burglar alarm?

Yes No Monitored

Fire alarm?

Yes No Monitored

Building replacement cost value

Coverage values

Business personal property value (contents, equipment, inventory)

Business income / loss of income coverage needed?

Yes No

Months of business income coverage needed

Equipment breakdown coverage needed?

Yes No

Signs or outdoor property to insure?

Yes No

Describe and estimated value of signs / outdoor property

Property risk

Is the property in a flood zone or near a body of water?

Yes No Unknown

Any property losses in the past 5 years?

Yes No

Describe losses — include dates and amounts paid

5

Commercial Auto

Section unlocked

Coverage preferences

Bodily injury coverage

Property damage coverage

Uninsured motorist coverage

Yes No

Medical payments

Collision deductible

Comprehensive deductible

Hired auto coverage

Yes No

Non-owned auto coverage

Yes No

Any vehicles used to transport passengers for hire?

Yes No

Any vehicles used to haul goods for others for compensation?

Yes No

Any vehicles with special equipment or modifications?

Yes No

Describe special equipment or modifications

Vehicles

Number of vehicles

Drivers

Number of drivers

Auto claims history

Any accidents, claims or violations in the past 5 years?

Yes No

Describe — include dates, driver involved, and outcome

6

Additional Information

Additional notes, coverage requests, or anything else you'd like to share

How did you hear about us?

Commercial Insurance
Quote Request

Business Information

Coverage Selection

General Liability

Commercial Property

Commercial Auto

Additional Information

Quote request received

Wayne Lilly Insurance

Commercial InsuranceQuote Request

Business Information

Coverage Selection

General Liability

Commercial Property

Commercial Auto

Additional Information

Quote request received

Commercial Insurance
Quote Request