Business Insurance Quotation Form

For a Business Insurance quotation for the state of Kentucky, please fill out the following form and click the submit button. An agent with Simms & Montgomery will contact you to review a personalized quotation as soon as possible. Please note that Simms & Montgomery is authorized only to write insurance in the state Kentucky.

Thank you for your quotation request. Questions? Please contact us.

In order to provide you with the most accurate quote available, please include your Social Security Number. However, if you would rather not enter that information, we can still provide you with a quote.

Personal Info

Name (first, middle I. last) :

Address Line 1:

Address Line 2:

Address (city, state, zip code) :

Home Phone:

Work Phone:

E-mail:

Fax:

Best time to call:

Social Security # (required):

Business Information

Type of business:

Other:

Number of employees:

Full-time Part-time Annual payroll

How long in business:

years

Approximate annual sales:

Please provide a brief description of your business and clientele:

Coverage Information

Coverage:

Commercial Auto	General Liability
Commercial Property	Business Personal Property
Computer Coverage	Umbrella
Workers' Compensation	Other

Comments and additional pertinent information:

Submitting an insurance quotation request to Simms & Montgomery does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Simms & Montgomery to confirm binding or altering coverage.