Request A Quote - Sweeney Insurance, Inc.

Commercial Insurance Quote

* = Required Field

Contact Name*

Email Address*

Business Name

Mailing Address

Business Phone

Business Fax

County of Business

FEIN Numner

Current Carrier

Company Name

Policy Expiration Date

Current Coverages

BondCommercial Property
Disability
Professional Liability

Commercial AutoCommercial Umbrella
Group Health
Workers' Compensation

Commercial Liability
Directors & Officers Liability
Group Life
Other:

Business Information

# of Full-Time Employees
# of Part-Time Employees

How many locations?
How many years in Business?

Please give a brief description of your business and clientele:

Location Address

Occupancy Status
OwnerTenant

Year Built

% Occupied

Sprinklers

Yes

Construction Type

Stories

# Basements

Sq. Footage

Burglar Alarm

Yes

Building Value

Contents

Other Property (specify)

Annual Gross Revenues:

Annualized Payroll

Cost of Subcontracted Work

Liability Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000

Describe all claims from the past 5 years

Additional Comments

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Homeowner's Insurance Quote

* = Required Field

Contact Name*

Email Address*

Phone

Address

Current Insurance Information

Do you presently have homeowner's insurance?

Yes

Company Name

Expir. Date

Current Annual Premium

Have you filed for bankruptcy within the past 7 years?

Yes

Deductible Desired

Amount of Liability

Earthquake Coverage Desired?

Yes

Home Information

Estimated Replacement Cost

Square Footage

Year Constructed

How Many Floors?
1 story1.5 story2 storyBi-levelTri-levelOther:

Type of Construction
WoodStuccoMasonryBrick VeneerAluminum SidingOther:

Other Features (check all that apply)

Dead BoltsSmoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm

Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits

List any claims in past 3 years:

Amount Paid

Claim Type

Description

Estimated value of your personal property:

Jewelry & Watches

Furs

Silver

Stamp & Coin Collections

Firearms

Fine Arts & Breakable Items

‍
‍Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Auto Insurance Quote

* = Required Field

Insured Name*

Email Address*

Address

Phone

Current Insurance Information

Do you presently have auto insurance?

Yes

Company Name

Renewal Date

Current Annual Premium

Have you been cancelled or non-renewed in the past 3 years?

Yes

Desired Coverage

Bodily Injury Liability

Property Damage Liability

Medical Payments

Uninsured Motorist Liability

Uninsured Motorist Property

Underinsured Motorist Liability

Underinsured Motorist Property

Comprehensive Deductible

Collision Deductible

Rental Reimbursement

Yes

Towing & Labor

Yes

Primary Driver

License State

GenderMaleFemale

Marital Status

MarriedSingle

DivorcedWidowed

Relationship to Applicant

Applicant Occupation

Good Student (3.2 GPA or higher)

Yes

Driver Training

Yes

Tickets & accidents (last 5 years)

Secondary Driver

License State

GenderMaleFemale

Marital Status

MarriedSingle

DivorcedWidowed

Relationship to Applicant

Applicant Occupation

Good Student

Yes

Driver Training

Yes

Tickets & accidents (last 5 years)

Additional Drivers

Please provide the names and birthdates of any other residents in your household licensed to drive.

Name

Birth Date

Vehicle Info

Year

Make

Model

Vin

Annual Mileage

License State

# of Doors

Safety Features4-Wheel DriveAlarm SystemAir BagsAnti-lock brakesAuto-seatbelts

Vehicle 2 Info

Year

Make

Model

Vin

Annual Mileage

License State

# of Doors

Safety Features4-Wheel DriveAlarm SystemAir BagsAnti-lock brakesAuto-seatbelts

‍Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Boat/Yacht Insurance Quote

* = Required Field

Name*

Email Address*

Phone

Address

Date of Birth

Boat Information

Year

Make & Model

Hull Value or Purchase Price

Length of Vessel

Year, Make and HP of Engine

Hull ID Number

Max Speed

Hull Material
FiberglassWoodOther:

Fuel Type
GasDieselOther:

Amount of Hull Insurance*

Hull Deductible ....(of Hull Value)

$500

Other:

Medical Payments Coverage (up to $25,000)

Watercraft Liability
$300,000$500,000Other:

Trailer Value
# of months used per year

Navigation Area

Mooring or Marina Name

Mooring or Marina Address

Is vessel used commercially? *
YesNo

If vessel is used commercially please describe the operation

Years of Boating Experience

Loss Experience Past Five Years

Currently Insured By

Is this vessel for sale?

Yes

List Safety Gear

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Life Insurance Quote

* = Required Field

Type

Amount of Death Benefit

Insured Name

Email Address*

Mailing Address

Phone

Use tobacco

Yes

Gender

Male

Female

Height

Weight

Family Information

Spouse to be Insured?

Yes

Spouse Use Tobacco?

Yes

Spouse Gender

Male

Female

Spouse Height

Spouse Weight

Children

Yes

Insured's Financial Information

Occupation

Duties

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Health Insurance Quote

* = Required Field

Type

Amount of Death Benefit

Insured Name

Email Address*

Address

Phone

Use tobacco

Yes

Gender

Male

Female

Height

Weight

Family Information

Spouse to be Insured?

Yes

Spouse Use Tobacco?

Yes

Spouse Gender

Male

Female

Spouse Height

Spouse Weight

Children

Yes

Insured's Financial Information

Occupation

Duties

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Group Insurance Quote

* = Required Field

Contact Name*

Email Address*

Name of Business

Nature of Business

Business Phone

Business Fax

Address

Do you have existing medical coverage?

Yes

Current Plan

# of Employees

# of Employees Eligible

Current Carrier

Renewal Date

Current Rate

Renewal Rate

Flat Amount

Requested Insurance

# of Employees

# of Employees Eligible

Desired Deductible

Desired Co-Pay

Plan to Quote

Desired Co-Insurance

Class A Deductible

Class B Deductible

Class C Deductible

Class A Co-Insurance

Class B Co-Insurance

Class C Co-Insurance

Calendar Year Maximum

Disability Coverage

# of Employees

# of Employees Eligible

Current Plan

Short Term Disability

Long Term Disability

Current Carrier

Renewal Date

Current Rates STD

Short Term Disability

Renewal Rates STD

Elimination Period STD

Percentage Payable STD

Maximum Benefit STD

Duration Benefits STD

Current Rates LTD

Long Term Disability

Renewal Rates LTD

Elimination Period LTD

Percentage Payable LTD

Maximum Benefit LTD

Duration Benefits LTD

Employee census information including Date of Birth, Sex, Job Title and Earnings will be required. Loss information will be helpful and may be required on groups over 100 lives.

Please note any other pertinent information or requests for coverages:

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.