Commercial Insurance Quote Request

Thank you for the opportunity to quote your business insurance. Please complete the form below as thoroughly as possible. The more detail you provide, the faster we can find you the best coverage at the best price.

1Applicant Information

First Name*

Last Name*

Date of Birth*

Driver's License #*

License State*

Phone*

Email*

Preferred Contact*

Marital Status*

Street Address*

City*

State*

ZIP Code*

Co-Applicant's / Co-Owner's Information(if applicable)

First Name

Last Name

Date of Birth

Driver's License #

License State

Phone

2Company Information

Legal Entity Type*

Legal Business Name*

DBA / Doing Business As

Business Address*

City*

State*

ZIP Code*

Main Phone Number*

Email Address*

Website

Federal EIN (XX-XXXXXXX format)*

3Business Information

Year Business Established*

Number of Principal Managers / LLC Members / Officers

Number of W-2 Employees

Annual W-2 Employee Wages Total ($)

Number of 1099 Contractors

Annual 1099 Payments Total ($)

Annual Gross Sales / Revenue*

Describe your business operations in detail. What products or services do you provide? Who are your customers?*

4Current Insurance

Do you currently have business insurance in force?

Please upload your current declarations (dec) page or any additional documents in Section 10 — this helps us find you the most accurate quote.

5Prior Losses

Any claims or losses in the past 3 years?

6Coverages Needed

Select all coverages you are interested in. Additional questions will appear based on your selections.

General Liability (GL)

Commercial Property

Workers Compensation

Commercial Auto

Business Owners Policy (BOP)

Inland Marine / Equipment

Cyber Liability

Data Breach Coverage

Professional Liability / E&O

Directors & Officers (D&O)

Umbrella / Excess Liability

Other

7Additional Information & Consent

Is there anything else about your business we should know when preparing your quote?

Upload Documents (Optional)

Upload your current declaration page, policy documents, or any other relevant files. You can also take a photo directly from your phone.

Accepted: Images (JPG, PNG), PDF, Word docs. On mobile you can take a photo directly.

I certify that the information provided is accurate and complete to the best of my knowledge.*

I agree to be contacted by Lieck Insurance Agency by phone, email, or text regarding my quote request.