Business Insurance

Kelly & Co., Inc.

Request for Business Insurance Quote

PERSONAL INFORMATION

First Name:

Last Name:

Street Address

City

State

Michigan

Zip code

County

Contact Phone

Fax Number

Your E-mail address

CURRENT INSURANCE INFORMATION

Are you Currently Insured by Another Company?

YesNo

Insurance Carrier Name

Type of Business

Number of Years in Business

Business Classification (Corporation, LLC, etc.):

Describe Prior Insurance Claims

Claim History in Last 5 Years (Include all claims)

REQUESTED COVERAGES

Dwelling Coverage: $

Liability Coverage: $

Requested Deductible:

Describe Your Business

Employee's Annual Payroll Amount

Number of Employees

Annual Gross Revenue ($)

Square Footage of Business

Number of Stories

Other Business/Residences in this Building:

Safety Features:

Type of Coverage:

Liability Coverage (in Dollars)

Business Content Coverage (in Dollars):

Building Coverage (in dollars)

COMMENTS OR QUESTIONS

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..............	Kelly & Co., Inc 2575 S Van Dyke Rd, Suite 102 Marlette, MI 48453	Marlette: 800.257.3735 989.635.2649 Fax: 989.635.3744	Kingston: 888.843.3388 989.683.2419 Fax: 989.683.3107	Kelly & Co., Inc 5951 State Street, Kingston, MI 48741