This quote is for Massachusetts Businesses only
Applicant Information
Business Name:
Your Name:
Mailing Address:
City/State/Zip:	/ /
Home Phone:
Work Phone:
Email Address:
General Information
Business Type:		Individual Partnership Corporation Other other:
Business Activity:		retail % whole sale % service % contractor %
Do you perform work outside of Massachusetts?		Yes No
		If Yes, please describe:
Description of Business including Products and Services
Annual payroll:		$
Annual sales for current year:		$
Number of full time employees:		full time
Number of part time employees:		part time
Trade contractors license number:		#
Number of years in business
Percentage of work which is commercial:		%
Prior Insurance
Name of Prior Insurer
During the past 3 years has an insurer canceled, declined or non-renewed coverage?		Yes No
		If Yes, please describe:
All Applicants
How many years has the applicant been in business?		years
Does the applicant own or operate any other business?		Yes No
		If Yes, please describe:
Does the applicant hire contractors or subcontractors to perform work under the applicants name/ authority?		Yes No
		If Yes, please describe:
If the applicant performs work for others, what percentage of the applicants work is subcontracted?		%
Does the applicant require each contractor or subcontractor to provide a certificate of insurance?		Yes No
Does the applicant import foreign products or sell products under own label?		Yes No
Does the applicant sell used or restored merchandise?		Yes No
Does the applicant draw plans, designs or specifications?		Yes No
Does the applicant have professional Errors & Omissions Liability Insurance in place?		Yes No
Does the applicant ever sign agreements which hold others harmless?		Yes No
Does the applicant sponsor any athletic teams or host any special events?		Yes No
Location Information
Year of construction		years
Class of construction		Frame Masonry Masonry Non-combustible Fire Resistive
Sprinkler system		Yes No
		Percentage of building covered %
Public protection		ISO Protection Class
		Distance from fire station ( in miles)
		Distance from nearest hydrant (in feet)
Costal Distance from ocean ( if within 5 miles)		miles
You have completed the preliminary business/ commercial insurance application. Please review to be sure all required information has been provided. Thank you for considering Gulde Insurance. We will provide you with a quote within 48 Hours of our receipt of your request
Please provide the following information. Who referred you to Gulde Insurance?
How did you hear about Gulde Insurance?