Technology Florida Insurance Quote

Business Information

Business name ✶

Street address ✶

City ✶

State ✶

Zip ✶

Years in business ✶

Legal entity ✶

Annual revenue ✶

# of owners/partners ✶

# of full-time employees ✶

# of part-time employees ✶

# of sub-contractors ✶

Description of operations ✶

Annual payroll ✶

Are you currently insured? ✶

Yes No

Name of current insurance company ✶

Current expiration date ✶

Any claims in the past 5 years? ✶

Yes No

If yes, please provide loss runs from the current insurance company for the last 5 years, and email them to membersinsurancecentercommercial [at] floridamic [dot] org

FEIN

Limits of Liability Desired ✶

Any of the following in the last 10 years? ✶

Bankruptcy

Repossession

Felony Conviction

None of the above

Contact Information

First name ✶

Last name ✶

Phone number ✶

Email ✶

Title ✶

Date of birth ✶

Co-Owner Name

Co-Owner Relationship

Co-Owner Date of Birth

Coverage Information

Currently Insured? ✶

Yes No

Please email your current policy to us at miccommercial [at] floridamic [dot] org

Comments

Binding Agreement

I understand that coverage cannot be bound or altered until the information has been confirmed by one of our representatives by phone or email. ✶

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