Business Insurance Quote — PRG Brokerage Complete only what applies. Selecting coverages below will reveal the relevant sections. Contact & Business Info Contact Name Title/Role Email Phone Legal Business Name DBA FEIN Entity Type Select…LLCCorporation (C/S)Sole ProprietorPartnershipNonprofit Years in Business Website Physical Address Mailing Address (if different) Describe Your Operations NAICS (if known) Annual Gross Receipts ($) Estimated Annual Payroll ($) Number of Employees Which coverages do you want quotes for? General Liability / BOP Commercial Property Workers’ Comp Commercial Auto Professional Liability (E&O) Cyber Umbrella / Excess Inland Marine / Equipment Bonds General Liability / BOP Desired Liability Limits Select…$1M / $2M$2M / $4MOther (note below) Annual Subcontracted Cost ($) Percentage of Work Subcontracted (%) Any Work at Heights > 2 Stories?Select…NoYes Any Work in NY or NJ?Select…NoYes Gross Sales by State (optional) Premises/Operations Details Commercial Property Building Year Built Construction TypeSelect…Masonry/BrickFrameJoisted MasonryNon-CombustibleOther Protection (Sprinkler/Alarm) Replacement Cost ($) Business Personal Property ($) Stock ($) Business Income ($) Occupancy Update Years (Roof/Elec/Plumb/HVAC) Property Notes Workers’ Compensation Estimated Annual Payroll ($) Owners Included?Select…NoYes # Full-Time # Part-Time Job Class Breakdown Commercial Auto # Drivers # Vehicles Radius of Operation (miles) Filings Needed?Select…NoYes (ICC/MC/USDOT) Vehicle List (VIN / Year / Make / Model / GVW / Use) Garaging Address(es) Professional Liability (E&O) Profession Retroactive Date (if any) Desired LimitsSelect…$1M / $1M$2M / $2MOther (note below) Notes Cyber Liability # Customer/Patient Records MFA on email/admin?Select…YesNo Accept Credit Cards?Select…YesNo Desired LimitSelect…$250k$500k$1M$2M+ Notes Umbrella / Excess Desired Limit Select…$1M$2M$5M$10M+ Underlying Policies In Place? Select…GLGL + AutoGL + Auto + WCOther Inland Marine / Equipment Equipment Schedule (describe or upload below) Bonds Bond Type Select…License & PermitBidPerformance/PaymentFidelityCourt/Other Bond Amount ($) Obligee (Who requires it) Current Insurance & Losses Current Carrier(s) Policy Expiration Annual Premium ($) Losses in last 5 years?Select…NoYes (describe below) Loss Descriptions Uploads (optional) You can attach PDFs or images (license, current policy, loss runs, equipment lists). Business License / Photo ID Current Policy (Dec Page) Loss Runs Additional Files I agree to be contacted by PRG Brokerage about this quote. Request Quote
