Get a Quote - Business
 

Please enter the following information and click "Submit Quote Request" at bottom.

Basic Information  
Business Name:
Full Name:
Address Line 1:
Address Line 2:
City:
State:
Zip:
County:
Phone:
Fax:
Email Address:
   
Current Insurance Company (not agency)
Company Name:
Policy Expiration Date:
   
Current Coverages (check all that apply)
Bond   Disability
Commercial Auto   Group Health
Commercial Liability   Group Life
Commercial Property   Professional Liability
Commercial Umbrella   Workers' Compensation
Directors & Officers Liability   Other 
   
About Your Business
Number of full-time employees:
Number of part-time employees:
How long in business: yrs.
How many locations:
Annual Sales $:
   
Brief Description of Your Business and Clientele
   
First Property / Premises Information
Address:
  Owner Tenant
Year Built:
% Occupied:
Sprinklers? Yes No
Construction Type:
# Stories:
# Basements:
Sq. Footage:
Burglar Alarm: Yes No
Building Value $:
Contents $:
Other Property ( Specify)
 
Second Property / Premises Information (if applicable)
Address:
  Owner Tenant
Year Built:
% Occupied:
Sprinklers? Yes No
Construction Type:
# Stories:
# Basements:
Sq. Footage:
Burglar Alarm: Yes No
Building Value $:
Contents $:
Other Property ( Specify)
 
Third Property / Premises Information (if applicable)
Address:
  Owner Tenant
Year Built:
% Occupied:
Sprinklers? Yes No
Construction Type:
# Stories:
# Basements:
Sq. Footage:
Burglar Alarm: Yes No
Building Value $:
Contents $:
Other Property ( Specify)
   
Liability
Class of Business:
Other:
Annual Gross Sales (before taxes):
Number of employees:
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested $300,000 $500,000 $1,000,000 $2,000,000
Describe Any Claims You Have Had in the Last 5 Years
   

 

 

 
Franklin Insurance

104 13th Street
Franklin, PA 16323
(814) 432-4523 - (800) 346-8714
(814) 432-8644 (fax)

  Titusville Insurance

314 South Franklin Street, Suite D-1
Titusville, PA 16354
(814) 827-8888
(814) 827-3557 (fax)

© 2006 - Franklin Insurance Agency, Inc.