Palm Beach Insurance Group, Inc. - Peace Of Mind. Palm Beach Style.

LET US QUOTE YOUR BUSINESS INSURANCE!

We would like to provide you with a free, no-obligation quote for your business. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Please note that this form is a PRICE QUOTE REQUEST ONLY. Filling out and submitting this form DOES NOT bind coverage in any way. The only way coverage can be bound is when an agent of Palm Beach Insurance Group has issued the binder or policy and then notified you that it has been issued. IF YOU DO NOT AGREE WITH THIS DISCLAIMER, DO NOT CONTINUE!

By submitting this Quote Form, you confirm that you have read and agree to the above disclaimer.

GENERAL INFORMATION
Company or Name:*		Contact:
Address:		City:
State:		Zip:
Phone:*		Alternate Phone:
Fax:		Email:*
How would you like to be contacted?:*		Fein or S.S.#:
Business Experience Years:		Year Started Business:
Entity Type:		No. of Employees:
Nature of Business:

GENERAL LIABILITY (Please provide us the desired limits you are looking for. If you do not know we will call you):
Liability:		Professional Liability:
Prod./Compl. Opps. Liability:		Property Rented:
Medical Expenses:		Deductible:
Payroll(min,15,000):		Sales:

PROPERTY COVERAGE(This will give us a basic idea of what you are looking for):
Deductible:		Property:
Betterments:		Business Income:
Other Coverage:		Amount:

PREMISE INFORMATION - Location 1
Street:		City:
County:		Zip Code :
City Limits:		Ownership Interest:
Year Built :		Square Footage:
Part Occupied:		Construction Type:
Roof Type :		Monitored Alarm:

PREMISE INFORMATION - Location 2
Street:		City:
County:		Zip Code:
City Limits:		Ownership Interest:
Year Built :		Square Footage:
Part Occupied:		Construction Type:
Roof Type :		Monitored Alarm:

ADDITIONAL LOCATIONS (Please enter the information requested above for any additional locations below):

RATING INFORMATION(Explain all yes answers in remarks below):
Are you a subsidiary of another entity?
Do you have a formal safety program?
Any Exposures to Flammables, Explosives, Chemicals?
Any Catastrophic Exposures?
Any policy or coverage declined, cancelled or non-renewed in the past 3 years?
Any past losses due to sexual abuse or molestation allegations, discrimination, negligent hiring?
During the past 10 years, has any applicant been convicted of any degree of the crime of arson?
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
Remarks for all yes answers:
Additional Comments or Requests:

Click Here to Clear This Form	Click Here to Email This Form to Us!

If you do not hear from us in a reasonable amount of time, it means we did NOT receive this request for a quote, so please call our office at (561) 624-0361.
Thank you for allowing us the opportunity to serve you!

To discuss your home & valuables coverage needs, please contact Mark Saccal at (561) 624-0361 or email us at info@palmbeachinsgroup.com

Need Help?

Call 561.624.0361,
email us at: info@
palmbeachinsgroup.com,
or visit us at:
13700 U.S. Highway One,
Suite 102
Juno Beach, FL 33408

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