Lee County Inside

Commercial Insurance Quote
This form is a request for COMMERCIAL insurance coverage. Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Name:

Address (city, state, zip code):

E-mail:

Telephone:

Fax:

Type of business:

Other:

Number of employees:

Annual Payroll:

Full-time Part-time

How long in business:

years

Approximate annual sales:

Please provide a brief description of your business and clientele:

Coverages:

Commercial Auto	General Liability
Commercial Property	Business Personal Property
Computer Coverage	Umbrella
Workers' Compensation	Other

Comments and additional pertinent information:

390 Pondella Road Suite 1 * North Ft. Myers, FL 33903 * Phone: 239.656.5551 * Fax: 239.656.0640

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