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Solutions
Industries
Insights
Self Service
Request a Proposal
- Commercial Insurance
- Personal Insurance

Request a Proposal

Commercial

Please complete and submit the information below and we’ll have a specialist get back to you as soon as possible during our normal office hours.

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General Information

Desired effective date of coverage:

Have you spoken to anyone at Collier Insurance?

Yes

No

I spoke with (name):

Legal Business Name:

Mailing address:

Phone:

Email:

Website address:

FEIN:

Contact Name:

Contact Email Address:

Contact Phone Number:

Legal Entity:

Year Business Began:

Years of owner's experience in industry:

Annual revenues:

Annual payrolls:

Number of part-time employees:

Number of full-time employees:

Description of your business operations:

Any autos owned by business?

Do employees use their own autos?

Yes

No

Do you have current insurance in place?

Yes

No

If yes, expires on:

Have you had any insurance claims?

Yes

No

If yes, please describe:

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Loss runs (claims history)

Up to 5 years of claims history may be requested

Additional named insureds/FEINS:

General Liability

General Liability

Aggregate Limit Desired

Occurence Limit Desired

Do you use sub-contractors?

Yes

No

Anual Cost for your Sub-contractors

Do you retain certificates from your sub-contractors?

Yes

No

Are you required to provide certificates of liability to others?

Ye

No

Contracts: Is Additional Insured status required?

Contracts: Is Waiver of Subrogation required?

Contracts: Is Primary Non-Contributory wording required?

Contracts: Is Non-Owned/Hired Auto Liability required?

Are Professional Services Provided?

Yes

No

Professional Service Description:

Total annual website sales

Employee Benefits Liability coverage desired?

Yes

No

Umbrella Liability coverage desired?

Yes

No

Umbrella Liability Limit required

Do you require Professional Liability coverage?

Ye

No

Do you require Errors & Omissions Liability coverage?

Yes

No

Do you require Directors & Officers Liability coverage?

Yes

No

Do you require Employment Related Practices Coverage?

Yes

No

Do you require Cyber Liability Coverage?

Yes

No

Current Coverage Information

Current Coverage Information

Name of your current insurance company:

Current Policy Number:

Current Expiration date on policy:

Have you filed an insurance claim?

Yes

No

Briefly describe your loss:

Property Information

Property Information

Location Address:

Building Owner’s Name:

Do you Own or Rent the building?

Own

Rent

Please indicate type of other occupants in building

Office

Retail

Restaurant

Other

Year Built:

Construction Type: (Frame, Masonry/block, Steel, Non-combustible, etc.)

Roof material: (metal, shingles, built up etc.)

Total square feet of building:

Total square feet you occupy:

Number of Stories:

Fire Protection sprinklered?

Ye

No

Central Station Burglar Alarm System?

Yes

No

Smoke/Fire Detectors?

Yes

No

Has roof been replaced/repaired?

Yes

No

Year:

Has plumbing been updated?

Yes

No

Year:

Has Heat/AC been updated/replaced?

Yes

No

Year:

Has Electrical been updated?

Yes

No

Year:

Wire type (copper/aluminum/unknown)

Copper

Aliminum

Unknown

Building Limit required:

No coverage required:

No coverage required:

Contents (personal property) limit required:

Deductible desired:

$1,000

$2,500

Other:

Business Income Coverage desired?

Yes

No

If leasing to others, what is the monthly rental income (total rents)?

Flood coverage required (limit)?

Yes

No

Earthquake coverage required (limit)?

Yes

No

Wind or Hail coverage required?

Yes

No

Name of Mortgage Company

Name of Landlord

Address:

City/State/Zip Code

Mortgage loan number

Is this a Triple Net Lease contract?

Yes

No

Workers Compensation

Workers Compensation

List all states of operation:

Experience mod factor: (if applicable) – Current copy of mod worksheet if applicable

Officers-List all owners/officers below. % ownership must = 100%

Officers-List all owners/officers below.

% ownership must = 100%

Name:

Title:

Date of Birth:

% ownership:

Payroll:

Include/Exclude:

Name:

Title:

Date of Birth:

% ownership:

Payroll:

Include/Exclude:

Employers Liability:

Employers Liability:

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Bodily Injury by Accident (each accident)

Bodily Injury by Accident (each accident)

100,000

500,000

1,000,000

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Bodily Injury by Disease (policy limit)

Bodily Injury by Disease (policy limit)

100,000

500,000

1,000,000

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Bodily Injury by Disease (each employee)

Bodily Injury by Disease (each employee)

100,000

500,000

1,000,000

NCCI Code:

State:

Job Description:

Annual Payroll:

NCCI Code

State

Job Description

Annual Payroll

NCCI Code

State

Job Description

Annual Payroll

NCCI Code

State

Job Description

Annual Payroll

Commercial Auto Coverage

Commercial Auto Coverage

Coverage

Coverage:

Limit

Limit:

Deductible

Deductibles:

Include

Include:

Auto Liability

Auto Liability

$1,000,000 CSL

$1,000,000 CSL

N/A

N/A

Field label

Medical Payments

Medical Payments

$5,000

$5,000

N/A

N/A

Include

Uninsured Motorist

Uninsured Motorist

$1,000,000 CSL

$1,000,000 CSL

$300

$300

Include

Collision Coverage

Collision Coverage

$500 / $1,000 / $2,500

$500

$1,000

$2,500

Deductible

Include:

Comprehensive Coverage

Comprehensive Coverage

$500 / $1,000 / $2,500

$500

$1,000

$2,500

Deductible:

Include:

Towing

Towing

$50 / $75 / $100

$50

$75

$100

Deductible:

Include

Rental Reimbursement

Rental Reimbursement

$30/day / $50/day

$30/day

Option 2

Option 3

N/A

N/A

Include

Driver Information

Driver's Information

Name:

Name:

Date of Birth

Date of Birth:

State:

State:

License Number

License Number:

Tickets/Accidents?

Tickets/Accidents?

Driver 1 name

Driver 1 DOB

Driver 1 State

Driver 1 License Number

Driver 1 Tickets/Accidents?

Driver 2 Name

Driver 2 DOB

Driver 2 state

Driver 2 license number

Driver 2 tickets/accidents

Driver 3 Name

Driver 3 DOB

Driver 3 State

Driver 3 license number

Driver 3 ickets/accident

Vehicle 1

Vehicle 1

Year:

Make:

Model:

VIN

Gross Vehicle Weight

Cost New

Garaging zip code

Radius of use

Use of auto (delivery, service calls etc.

Assigned driver name

Name on vehicle registration

Vehicle 2

Vehicle 2

Year:

Make:

Model:

VIN:

Gross Vehicle Weight:

Cost New:

Garaging zip code:

Radius of use:

Use of auto (delivery, service calls etc.):

Assigned driver name:

Name on vehicle registration:

Vehicle 3

Vehicle 3

Year

Make

Model

VIN

Gross Vehicle Weight

Cost New

Garaging zip code

Radius of use

Use of auto (delivery, service calls etc.)

Assigned driver name

Name on vehicle registration

Vehicle 4

Vehicle 4

Year

Make

Model

VIN

Gross Vehicle Weight

Cost New

Garaging zip code

Radius of use

Use of auto (delivery, service calls etc.)

Assigned driver name

Name on vehicle registration

ommercial High Value (>$5,000) Equipment Schedule

Commercial High Value (>$5,000) Equipment Schedule

Item 1

Item 1

Year

Make

Model

Serial #

Value

Owned/Rented?

Loss Payee? (Name/address)

Additional Insured? (Name/address)

Item 2

Item 2

Year

Make

Model

Serial #

Value

Owned/Rented?

Loss Payee? (Name/address)

Additional Insured? (Name/address)

Item 3

Item 3

Year

Make

Model

Serial #

Value

Owned/Rented?

Loss Payee? (Name/address)

Additional Insured? (Name/address)

Item 4

Item 4

Year

Make

Model

Serial #

Value

Owned/Rented?

Loss Payee? (Name/address)

Additional Insured? (Name/address)

Item 5

Item 5

Year

Make

Model

Serial #

Value

Owned/Rented?

Loss Payee? (Name/address)

Additional Insured? (Name/address)

Item 6

Item 6

Year

Make

Model

Serial #

Value

Owned/Rented?

Loss Payee? (Name/address)

Additional Insured? (Name/address)

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About Us
Solutions
Industries
Insights
Self Service
Request a Proposal
- Commercial Insurance
- Personal Insurance

Mon-Fri: 8:30am-4:30pm CST
Sat-Sun: Closed

606 South Mendenhall
Memphis, TN 38117

Phone: (901) 529-2900
Toll Free: (866) 600-2655
Fax: (901) 529-2916

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