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On-Line Commercial General
Liability Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Business Name:
Property Address:
City:
State: (Must be Pennsylvania)
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Underwriting Information
 
Date Coverage Needed:
 
Prior Carrier:
 
Describe Business:
 
Gross Annual Receipts: $
 
Gross Annual Payroll: $
 
Square Footage of
Your Business Location:
$
 
Number of Employees:
 
Tell us what kind of
commercial coverage you
are looking for, and why:
 
Prior Claims? Yes No
Describe claims in detail:
 

Limits & Coverages:
Liability Limits: $100,000    $300,000
$500,000    $1 Million
 
Business Contents Needed?
If so, list type and amount:
 
Comments/Remarks:
 
Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone


Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency release this information via the method you have chosen, and to release us any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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For Insurance Information contact one of the Qualified Staff at:
Specialty Insurance Agency     567 Kelly Blvd. (PO Box 116)     Slippery Rock, PA  16057
E-Mail Questions or Service Needs at: service@specialtyinsuranceagency.net
Phone: 800-782-6459 (Toll-free) 724-794-5081 (Local), or by Fax at: 724-794-3859
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