Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
Request for Insurance Quotation
Complete Business Information, plus any sections for which you are seeking a quote.
Ignore sections for which you do not want coverage quoted.
Return by fax or email. Contact information is below.
Business Information
Name:
Mailing Address:
City, State, Zip:
Phone:
Fax:
Email:
Inspection Point of Contact:
Accounting Point of Contact:
Corp LLC Sole Prop
FEIN or SSN:
Year Started:
Current Insurance Company(s):
Expiration Date(s):
Total Yearly Premium(s):
Street Address
Location #1
Location #2
Location #3
What does your business do? Describe all operations:
Additional Named Insureds:
Attach Separately
5 Year, currently valued Loss Runs. (Ask your existing insurance agent/company for these
and they should have them to you within 24 hours. If in business less than five years, send
what you have. If no prior insurance, ignore.)
Explain any losses over $5,000
Submit
Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
Property Do Not Quote
Attach as many sheets as necessary
Location #: Building #:
Insurance Values
Building: $
Contents: $
Business Income: $
Miscellaneous: $
Responding Fire Co:
Distance to Hydrant:
Year Built: Sq Ft:
Year Updated:
Roof Wiring
Plumbing Heating
Alarms: Fire Burglar Both
Local Only Central Station
Heat: Oil Electric Other
Sprinklers?
Construction: (frame, masonry, etc.)
Roof: (metal, composition shingle, etc.)
Siding: (metal, vinyl, wood, etc.)
Location #: Building #:
Insurance Values
Building: $
Contents: $
Business Income: $
Miscellaneous: $
Responding Fire Co:
Distance to Hydrant:
Year Built: Sq Ft:
Year Updated:
Roof Wiring
Plumbing Heating
Alarms: Fire Burglar Both
Local Only Central Station
Heat: Oil Electric Other
Sprinklers?
Construction: (frame, masonry, etc.)
Roof: (metal, composition shingle, etc.)
Siding: (metal, vinyl, wood, etc.)
Location #: Building #:
Insurance Values
Building: $
Contents: $
Business Income: $
Miscellaneous: $
Responding Fire Co:
Distance to Hydrant:
Year Built: Sq Ft:
Year Updated:
Roof Wiring
Plumbing Heating
Alarms: Fire Burglar Both
Local Only Central Station
Heat: Oil Electric Other
Sprinklers?
Construction: (frame, masonry, etc.)
Roof: (metal, composition shingle, etc.)
Siding: (metal, vinyl, wood, etc.)
Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
General Liability Do Not Quote
Limits
Per Occurrence $1,000,000 $2,000,000 Other: $
Aggregate $1,000,000 $2,000,000 $3,000,000 Other: $
Location #1: Yearly Est. Gross Sales: $ Yearly Payroll: $
Location #2: Yearly Est. Gross Sales: $ Yearly Payroll: $
Location #3: Yearly Est. Gross Sales: $ Yearly Payroll: $
Do you currently offer health insurance to your employees?
Business Auto Do Not Quote
Coverage Limits
Liability $500,000 $1,000,000 $1,500,000 Other: $
Uninsured Motorists (UM): $500,000 $1,000,000 $1,500,000 Other: $
Underinsured Motorists (UIM) $500,000 $1,000,000 $1,500,000 Other: $
Medical $2,000 $5,000 $10,000 Other: $
PIP (if available in your state) $2,000 $5,000 $10,000 Other: $
Physical Damage Deductible: $500 $1,000 $2,500 Other: $
Garaging address (if different than mailing):
Cities where you operate: Radius in Miles:
Any other vehicles owned but not listed? Yes No
Complete and Attach separately:
Driver List (example below)
Vehicle List (example below)
Internal Use Only:
1 Any Auto 2 All Owned Autos 7 Listed Autos 8 Hired Autos 9 Non-owned Autos
Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
Vehicle List
Attach only if quoting Business Auto. Use this form or attach a copy from your existing policy.
Total
Seating
Year
Make
Model
VIN
$ Value
Capacity*
Liab
Comp
Coll
Med
PIP
1
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2
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7
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11
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12
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* Include driver in seating capacity.
Liab = Liability
Comp = Comprehensive
Coll = Collision
Med = Medical Payments
PIP = Personal Injury Protection
Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
Driver List
Attach only if quoting Business Auto. Use this form or attach a copy from your existing policy.
Name
Date of Birth
License #
State
Licensed:
Years
Experience
# of Traffic
Violations*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
* Attach MVRs from your file
Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
Workers’ Compensation Do Not Quote
Coverage Limits
$100,000/$500,000/$100,000
$500,000/$500,000/$500,000
$1,000,000/$1,000,000/$1,000,000
Include with this application
Current experience modification worksheet. Only applicable for businesses in operation four
years or more. If your state is an NCCI state, obtain yours for free by calling them directly
at 800.622.4123.
All payroll estimates yearly
Owners / Officer Payroll
Complete for any owner / officer with over 5% ownership interest.
Name Date of Birth Ownership % Include/Exclude? Payroll Estimate
$
$
$
$
Staff Payroll by Classification
Location
No.
What do your employees do?
Appro
x No.
of EE's
Annual
Payroll
Estimate
Internal
Use.
Class
Code
1
Example 1: Drive forklift. Move wood in lumber yard.
4
$100,000
1
Example 2: Office / Clerical
2
$50,000
Bankers Insurance LLC
4490 Cox Road, Glen Allen, VA 23060
Phone: (877) 606-1375 • Fax: (800) 899-0146
Sales@BankersInsurance.net • www.BankersInsurance.net
I would like to hear more about insurance for:
Umbrella Liability
Cyber Liability/Data Breach
Business Income With Extra Expense
Inland Marine
Flood
Boat/Protection & Indemnity/Jones Act
Transportation
Ocean Marine
Employee Dishonesty
Employment Practices Liability
Directors and Officers
Employee Benefits Liability
Fiduciary Liability
Health – Group or individual
Life – Group or individual
Disability – Group or individual
Long Term Care – Group or individual
Yes
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No
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Other Comments/Questions/Information:
Applicant Signature: Date:
