Business Name:
Premises Address: City: Florida Zip Code: Contact Name: Phone #: Ext #: Fax: Years in Business: Email Address: (Required) Description of Operations or SIC code: Commercial Marine Insurance Coverage Desired: (check as many boxes as desired) Terminal Operators Legal Liability Ship Repairer's Legal Liability Wharf Owners Liability (Wharfinger) Stevedoer's Legal Liability Maritime Employers Liability USL&H Worker's Compensation CGL/Marine Liability Other Florida Employee & Business Information: # of full-time employees: # of part-time employees: # of locations: Estimated Annual Payroll: $ Select all that apply to your Florida commercial marine business: Work on vessels, docks, or bridges over water Operate or lease watercraft Work above 15 feet Require out of state travel Use Subcontractors Pre-employment physicals Offer safety incentive programs Store, treat, dispose, or transport hazardous waste Other Claims in the last 3 years: Description of claims: Current Insurance Company: Policy Expiration Date: (mm/dd/yyyy) Current Yearly Insurance Premium: $ Additional Information or Comments Click on the "Submit Quote Information" button below to send your Florida Commercial Marine insurance quote request. Information received from this Florida commercial marine insurance quote form sent to "YOUR AGENCY NAME" will be for our use only and will not be sold, given to or distributed to any other parties. A quote will be based on the Florida commercial marine insurance information provided and does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not entitle you to Florida Commercial Marine insurance. We are licensed in Florida and will not provide quotes for other states. Copyright 2017 OasisEarth Internet Group, All Rights Reserved
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