Business Insurance Quote Form

PERSONAL INFORMATION
Business Name*
Contact Name*
E-Mail*
Insured Address
City		State	Zip
Business Phone
Fax
Best Time to Contact


	*Required Fields

BUSINESS INFORMATION
Type of Business
Number of Employees	Full-time Part-time
Annual Payroll
Years in Business	years
Approximate annual sales
Please provide a brief description of your business

COVERAGE INFORMATION
General Liability	Commercial Auto
Business personal Property	Commercial Property
Umbrella	Computer Coverage
Other	Workers' Compensation
Please provide us with any additional information


	Submitting an insurance quote request to Salhaney Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Salhaney Insurance Agency to confirm binding or altering coverage.






	5264 Washington Street West Roxbury, MA 02132 (617)325-5555 fax (617)323-5199


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