Commercial Insurance Request

Business Name

Contact First Name

Contact Last Name

Phone

Email

Property Address

Mailing Address (if different)

Business Type / Industry

Number of Employees

Annual Revenue

Business Structure

What type of coverage are you looking for?

Description Of Business

Do you own or rent your space?

Build Square Footage

Year Built

Construction Type

Do you have insurance on this property?

Current insurance carrier?

How did you hear about us?

Note any additional details. (If applicable, desired coverage limits, claim details, etc.)

Upload your declaration page, etc. Or email documents to info@cmlegacyinsurance.com