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TEAM
The Team

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Industry Insurance Quote

Insured Information

Business Name(Required)

Insured Name | Main Contact(Required)

First Last

Mobile Phone(Required)

Is It OK To Text You?(Required)

Yes

No

Email(Required)

Business Address(Required)

Street Address City State ZIP Code

Federal ID (EIN)(Required)

Does The Company Have A Website?

Yes

No

Company Website

Industry (NAICS Code)(Required)

Description Of Business (What Do You Do?)(Required)

Years In Business(Required)

Number Of Employees(Required)

Annual Revenue(Required)

If new business, enter 12 months projected revenue.

Annual Payroll(Required)

If new business, enter 12 months projected payroll.

Please Select The Type(s) Of Insurance You Want Quoted

Coverage Type(s) Wanted(Required)

Business Owners / GL

Commercial Auto

Workers' Compensation

Commercial Umbrella

Cyber

EPLI

Landlord / Rental Property

Builders Risk

Surety Bond

Liquor Liability

Professional Liability

Other

If Other, please specify

Business Owners / GL Information

Current Business Owners Or GL Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Business Coverage Type(s)

GL Only

GL + Building

GL + Business Contents

GL + Building + Contents

Number of Location(s)/Building(s)

Same As Mailing Address

Main Address (Other Than Mailing)

Add'l Locations (Other Than Primary)

Primary Location Address(Required)

Street Address City State ZIP Code

Multiple Location | Building Info (enter address/coverage info for 3+ locations)

General Liability Limits

$1,000,000 | $2,000,000

$500,000 | $1,000,000

Building Coverage

Business Personal Property Coverage

Optional Coverage (Select All That Apply)

Cyber Liability

Employment Practices Liability

Professional Liability

Misc Business Insurance Notes

Upload Any BOP | CPKG Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Commercial Auto Information

Current Commercial Auto Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Combined Single Limit

$1,000,000

$750,000

$500,000

$300,000

UM/UIM Combined Single Limit

$1,000,000

$750,000

$500,000

$300,000

Medical Payment

$5,000

$1,000

$2,000

$10,000

None

Additional Policy Level Coverage(s)

Hired Auto

Non-Owned Auto

Number of Commercial Drivers

1

2

3

4

Commercial Driver 1(Required)

Date of Birth (Driver 1)

Driver's License Number (Driver 1)

Driver's License State (Driver 1)

Commercial Driver 2(Required)

Date of Birth (Driver 2)

Driver's License Number (Driver 2)

Driver's License State (Driver 2)

Commercial Driver 3(Required)

Date of Birth (Driver 3)

Driver's License Number (Driver 3)

Driver's License State (Driver 3)

Commercial Driver 4(Required)

Date of Birth (Driver 4)

Driver's License Number (Driver 4)

Driver's License State (Driver 4)

Number of Commercial Vehicles

1

2

3

4

Vehicle 1 Year

Vehicle 1 Make

Vehicle 1 Model

Vehicle 1 VIN

Vehicle 1 Original Cost New

Vehicle 1 Stated Value

Vehicle 1 GVW

Vehicle 1 Radius Of Operations

Vehicle 1 Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 1 Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 1 Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 Day / $1,500 Max

Vehicle 1 Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 2 Year

Vehicle 2 Make

Vehicle 2 Model

Vehicle 2 VIN

Vehicle 2 Original Cost New

Vehicle 2 Stated Value

Vehicle 2 GVW

Vehicle 2 Radius Of Operations

Vehicle 2 Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 2 Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 2 Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 Day / $1,500 Max

Vehicle 2 Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 3 Year

Vehicle 3 Make

Vehicle 3 Model

Vehicle 3 VIN

Vehicle 3 Original Cost New

Vehicle 3 Stated Value

Vehicle 3 GVW

Vehicle 3 Radius Of Operations

Vehicle 3 Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 3 Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 3 Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 Day / $1,500 Max

Vehicle 3 Road Service / Towing & Labor

No Coverage

$25

$50

$100

Vehicle 4 Year

Vehicle 4 Make

Vehicle 4 Model

Vehicle 4 VIN

Vehicle 4 Original Cost New

Vehicle 4 Stated Value

Vehicle 4 GVW

Vehicle 4 Radius Of Operations

Vehicle 4 Other Than Collision | Comprehensive Coverage

No Coverage

$0 Deductible

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 4 Collision Coverage

No Coverage

$100 Deductible

$250 Deductible

$500 Deductible

$1,000 Deductible

Vehicle 4 Rental Reimbursement / Extended Transportation

No Coverage

$15 Day / $450 Max

$30 Day / $900 Max

$50 Day / $1,500 Max

Vehicle 4 Road Service / Towing & Labor

No Coverage

$25

$50

$100

Misc Auto Information

Upload Any Auto Insurance Files You May Have

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Workers' Compensation Information

Current Work Comp Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Do You Know Your Workers Compensation Class Code(s)?

Yes

No

How Many Class Codes Do You Have?

1

2

3

Class Code (Main)

Class Code Payroll (Main)

Class Code (2)

Class Code Payroll (2)

Class Code (3)

Class Code Payroll (3)

Workers Compensation Limit

$1,000,000 | $1,000,000 | $1,000,000 (Recommended)

$500,000 | $500,000 | $500,000

$100,000 | $500,000 | $100,000

Misc Workers Compensation Information

Upload Misc Workers Compensation Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Commercial Umbrella Information

Current Commercial Umbrella Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Commercial Umbrella Notes

Upload Commercial Umbrella Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Cyber Information

Current Cyber Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Cyber Notes

Upload Cyber Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

EPLI Information

Current EPLI Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc EPLI Notes

Upload EPLI Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Landlord / Rental Property Information

Current Landlord / Rental Property Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Landlord / Rental Property Notes

Upload Landlord / Rental Property Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Builders Risk Information

Current Builders Risk Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Builders Risk Notes

Upload Builders Risk Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Surety Bond Information

Current Surety Bond Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Surety Bond Notes

Upload Surety Bond Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Liquor Liability Information

Current Liquor Liability Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Liquor Liability Notes

Upload Liquor Liability Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Professional Liability Information

Current Professional Liability Coverage?(Required)

Yes

No

Current Carrier

Effective Date(Required)

Misc Professional Liability Notes

Upload Professional Liability Files

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

How Did You Find ALLCHOICE Insurance?

Did you come across ALLCHOICE Insurance through Searching Online, Someone Telling You About ALLCHOICE (Referral), or Did You See An Ad (Advertisement)?(Required)

Online Search

Referral

Advertisement

Which search engine did you use? (e.g., Google, Bing, Yahoo)

What keywords or phrases did you use during your online search?

After finding us through the online search, what factors led you to choose ALLCHOICE Insurance?

Who referred you to ALLCHOICE Insurance?

Tell us more about your experience with the person or source who referred you.

Was there anything about the referral that influenced your decision to reach out?

Where did you encounter our advertisement? (social media, website, radio, TV, etc.)

Can you recall the content or message of the advertisement that caught your attention?

What prompted you to reach out to ALLCHOICE Insurance after seeing the ad?

Confirmation

Please review your information to ensure all fields are filled before submitting.(Required)

I confirm that all the information provided above is accurate and complete.

Δ

Personal Insurance

Commercial Insurance

ALLCHOICE Insurance
81 Broadway St, Suite 201-031
Asheville, NC 28801
828.277.5432

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Clemmons, NC 27012
336.360.8870

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236 Tamworth Dr.
Denton, NC 27239
888.400.2608

ALLCHOICE Insurance
7 Corporate Center Ct Ste B
Greensboro, NC 27408
336.540.0463

ALLCHOICE Insurance
419 Short St
Hendersonville, NC 28739
828.237.2327

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2018 Eastwood Rd
Wilmington, NC 28403
910.500.6116

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401 Olive St
Winston-Salem, NC 27103
336.765.1971

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