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Business Insurance Quote Questionnaire

Email*
Full Legal Name*
Date of Birth*

Example: January 7, 2019
Phone Number*
Email
Home Address*
Street Address Address Line 2 City State ZIP Code
Business Address-Location 1*
Street Address Address Line 2 City State ZIP Code
Business Address-Location 2 (if applicable)
Street Address Address Line 2 City State ZIP Code
Do you want policy information sent to your home or business address?*
Mark only one oval.
- Home
- Business
- Addresses are the same
Business Partner Name (if applicable)
Business Partner Address (if applicable)
Street Address Address Line 2 City State ZIP Code
Business Information
Business Entity*
Mark only one oval.
- LLC
- Sole Proprietor
- Corporation
- Partnership
Tax ID*
Name of Business Entity*
Doing Business As
Primary Business Operation*
Business Personal Property Amount- Location 1*
Business Personal Property Amount- Location 2 (if applicable)
Estimated Annual Sales*
Estimated Annual Payroll*
Business Inception Year*
How many employees do you have? (if applicable)
Do you own or rent the building your business is in?*
Mark only one oval.
- Own
- Rent
If you own, how much building coverage do you need? (answer N/A is not applicable)*
Business Auto Coverage
How many commercial vehicles do you have?
VIN Numbers of all vehicles
Garaging address of each vehicle
Names and Drivers License Numbers of Drivers of Each Driver
Have you had any auto claims in the last 5 years?*
Mark only one oval.
- Yes
- No
Miscellaneous Questions
Have you had any losses or claims in the last 5 years?*
Mark only one oval.
- Yes
- No
Have you ever been arrested?*
Mark only one oval.
- Yes
- No
Do you need Workers Compensation Coverage?*
Mark only one oval.
- Yes
- No
Who is your current home and auto insurance provider?*
Any other information we should know?
Comments
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Langer Insurance Agency

201 Point E Dr.
Nashville, Tennessee 37216

Phone: (615) 351-1298

Mon-Fri: 8:30am-4:30pm
Sat: By Appointment
Sun: Closed

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Langer Insurance Agency Provides home, auto, renters, life, and business insurance to All of Tennessee, Including Nashville, Cookeville and Lebanon.

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