(714) 751-4610 Costa Mesa, CA

Clarke Insurance Agency

Home
About Us
Quick Quote
Personal Insurance
Business Insurance
Customer Service
Blog
Contact

Business Quote Form

General Information

Contact Name *

Email *

Phone Number *

Type of Business

Business Name

Business Phone

Mailing Address

City

State

Zip/Postal Code

County

Current Insurance Company

Company Name

Current Insurance Coverages

Bond

Commercial Auto

Commercial Liability

Commercial Property

Liquor Liability

Directors & Officers Liability

Disability

Group Health

Group Life

Professional Liability

Workers' Compensation

Other

Business Information

# of Full-Time Employees

# of Part-Time Employees

How long in Business? (yrs)

How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

Address

City

State

Zip

Occupancy Status
Owner Tenant

Year Built

% Occupied

Sprinklers
Yes No

Construction Type

Stories

# Basements

Sq. Footage

Burglar Alarm
Yes No

Building Value

Contents

Other Property (specify)

Insurance Information

Business Personal Property Amount

Annual Gross Sales: (before taxes)

If Liquor Liability Required-Gross Annual Liquor Sales?

Annualized Payroll

Cost of any Subcontracted Work

Liability Limits Requested

$300,000

$500,000

$1,000,000

$2,000,000

Describe any claims you've had in the past 5 years

Additional Comments

Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message

Ready for the next step? Call us at (714) 751-4610 or Request a Quote

Home
About Us
Products
Customer Service
Blog
Contact Us
Website Disclaimer

Clarke Insurance Agency | 735 Baker Street | Costa Mesa, CA 92626 | (714) 751-4610

© 2009-2022 Websites by Agency Relevance, All Rights Reserved.