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Step One: Complete Form
Step Two: Review and Submit
Step Three: Finish
Welcome to E-Z Quote from A&M.

For fast service on your commercial accounts complete the form below and hit the “Step Two” button. Your submission will be electronically delivered to the next available Commercial Lines Underwriter.
 
Coverage Requested:  
Applicant Name:
Applicant Website Address:
Location address:
City: State: Zip Code:
Applicant's Primary Telephone #  
Description of Risk:
Prior Losses?
   If yes, include 5 years hard copy loss runs with submission.
Has applicant had any policies or coverage’s cancelled or non-renewed in the past three years?
Has applicant had prior Bankruptcy in the past 7 years?
Have any crimes occurred or been attempted on the premises within the last 3 years?
Expiring Carrier:
 Willing to Renew?:
Renewal Quote:
 If no, why?:
 
Target Premium:
General Liability Property
Limits Requested:
Payroll:
Number of Employees?:
Receipts:
Square Footage:
If Apt., # of Units:
Years in Business:
Does the applicant lease Employees to or from other Employers?
Building:
Contents:
Loss of Income:
Protection Class:
Construction Type:
Square Feet:
 Sprinkler?:
Central Alarm?:
Year Built:
 Is Building 100% on Circuit Breakers?:
If over 20 years old, provide building updates:
Building Updates / (Year)
Wiring (Yr):   Roof (Yr):   Heating/Air (Yr):   Plumbing (Yr):
What is the quality of the housekeeping?
Does the applicant have emergency lighting?
Is the Applicant:
  • (a) An owner of any other properties or business operations under this legal entity?
  • (b) Related to another entity through common ownership?
  • C) Subsidiary of another entity?

If yes to any of the above please explain.

    Comments & other Material Information:
     
Agency Name:
Contact Person:
Phone Number:
  Fax Number:
E-mail Address:
 
 
    (You will get a summary page to review before submitting)