Quote Request - Heritage Specialty Insurance - Commercial Insurance in Texas, Oklahoma, Arkansas & Washington

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Quote Request2024-03-20T20:30:01+07:30

Quote Request Form

Interested in a quote from Heritage Specialty Insurance? Please fill out the form below, upload an application at the bottom or contact us today!

1. AGENCY

2. CONTACT

3. AGENT PHONE NUMBER

4. AGENT EMAIL

5. NAME OF RISK

6. ADDRESS

7. MAILING ADDRESS IF DIFFERENT

8. CONTACT NAME AT INSURED

9. PHONE

10. FEIN IF AVAILABLE

11. BUSINESS TYPE

12. PERCENTAGE OF WORK

a. Residential

Commercial

Industrial

=100%

b. New

Remodel

Service

=100%

13. WEBSITE

14. YEAR BUSINESS STARTED

15. YEARS EXPERIENCE IF NEW IN BUSINESS

16. PRIOR COVERAGE?

Yes

No

17. LOSS HISTORY

18. DESCRIPTION OF WORK PERMORMED

19. NUMBER OF OWNERS

NUMBER OF EMPLOYEES

20. ANNUAL, GROSS SALES

21. PAYROLL OR LABOR COST BY TRADE

a.

b.

c.

d.

22. COST OF INSURED SUBCONTRACTORS

23. IF UNINSURED SUBS ARE USED, PLEASE DESCRIBE

24. REQUESTED LIMITS

500/500

1mil/1mill

1mil/2mil

25. OPTIONAL COVERAGE

a. ADDITIONAL INSURED?

Yes

No

b. WAIVER OF SUBROGATION?

Yes

No

c. EQUIPMENT (IF AVAILABLE)

d. INSTALLATION COVERAGE (IF AVAILABLE)?

Yes

No

e. HIRED/NON-OWNED AUTO (IF AVAILABLE)?

Yes

No

26. REMARKS

27. File Upload

Click or drag a file to this area to upload.

File 2

Click or drag a file to this area to upload.

File 3

Click or drag a file to this area to upload.

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