MA Business Liability Insurance Quotation Form

To request a Massachusetts Business Liability insurance quote please fill in this form with as much information as possible and click on the "submit" button at the bottom. One of our agents will contact you shortly.
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Email *
City State, ZIP
Business Address
Phone
Business Name *
Fax
Best Contact Method*
Best Time to Call
Type of Business:

Current Business Information

Contact Information

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Business Entity:
Sole proprietorship
Partnership
Corporation
LLC
Other
Describe the operation(s) performed by you and your employees:
Annual Gross Receipts Last Year ($):
Estimated Annual Gross Receipts this Year ($):
Number of Owners, Partners,Officers etc:
Employee payroll (not including owners, officers,clerical or sub-contractors) :
Number of Full Time Employees:
Number of Years in Business:
Number of Years Experience:
Number of Part Time Employees:
Do you use Consultants or Sub-Contractors?:
Yes
No
Renewal Date
Current Liability Insurance Company
If you want to clear ALL entries and start over click
Any Prior Year Losses?:
Yes
No
If Yes, Year(s) Loss(es) Occurred:
If Yes, Number of Consultants / Sub-Contractors
Business License#
EIN#
SSN#
Desired Limits of Coverage:
Square Footage of Office or Business Location:
Type of Building (Wood,, Concrete, Brick, Etc):
Number of Stories:
Other Businesses/Residences in Building?
Yes
No
If "Yes" Please Describe:
Protection Devices:
Sprinklers
Yes
No
ADT (or similar)
Yes
No
Fire Alarm
Yes
No
Security Camara
Yes
No
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Parent Prakop and Associates
Parent Prakop & Associates
Insurance Agency, Inc.    Stoughton, MA 02072
 
Phone: 781-344-9607
Fax:     781-344-1102
Massachusetts Association of Insurance Agents
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