CREATING PEACE OF MIND
SINCE 1964

Business Insurance Form

First name:

Last name:

Email:

Phone:

Business name:

Description of operations:

Years in business:

FEIN:

Annual sales:

Physical address of business:

List additional locations (address) here:

Building Information

Address:

Total Building Area:

Year Roof Upgraded:

Year Electrical Upgraded:

Year HVAC Upgraded:

Year Plumbing Upgraded:

Do you have any special equipment or business personal property:

Yes

If Yes, Description and value:

Commercial Auto coverage

Year, make, model, and VIN of all vehicles (or attach doc):

File upload

Driving radius:

0-50 miles

>50 miles

Full name, DOB, and Drivers License of ALL drivers (including Office Staff):

File upload

Workers Compensation Insurance

Number of full time employees:

Number of part time employees:

Classification Codes:

Annual payroll per class code:

Attach copy of existing policy:

Who referred you to Santa Cruz Insurance?:

Name of referral:

*Please note: if you leave this page before hitting submit, your form will not be saved.

Interested in other coverage options or a package discount?

Auto Insurance

Home Insurance

Life Insurance

Flood Insurance

Personal Umbrella Protection

Earthquake Insurance

CREATING PEACE OF MIND
SINCE 1964

Business Insurance Form

*Please note: if you leave this page before hitting submit, your form will not be saved.

Interested in other coverage options or a package discount?

CONTACT

Privacy Policy

SIGN UP

CREATING PEACE OF MIND SINCE 1964

Business Insurance Form

*Please note: if you leave this page before hitting submit, your form will not be saved.

Interested in other coverage options or a package discount?

CONTACT

Privacy Policy

SIGN UP

CREATING PEACE OF MIND
SINCE 1964