About Samel Insurance Agency

Personal service from a professional agency
serving New England for over 65 years!

About Paramount Insurance & Financial Services
Request for a Business Owner Insurance Quote

If your business is in Massachusetts, please click here

By completing and submitting this form, you agree that no coverage is bound and no policy is in effect until you are contacted by one of our agency representatives. All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible, please complete all areas that apply.
General Information
Name of Business
Contact Name
Street Address
City or Town
State
ZIP Code
County
Email Address required
Website Address
Business Telephone
Business Fax
Current Insurance Company (not agency)
Company
Policy Expiration Date
Current Coverages
Please select all that apply
Bond Disability
Commercial Auto Group Health
Commercial Liability Group Life
Commercial Property Professional Liability
Commercial Umbrella Workers' Compensation
Directors & Officers Liability Other
About Your Business
Number of full-time employees
Number of part-time employees
How long in business years
How many locations
Annual Sales (in dollars) $
Please give a brief description
of your business and clientele
Property / Premises Information 1
Street Address
  Owner   Tenant                          Occupied  %

Sprinklers?

Year Built

Construction Type

Number of Stories

Number of Basements

Square Footage

Burglar Alarm

Building Value $ Contents  $

Other Property (Specify)

  If no more property, jump to next section
Property / Premises Information 2
Street Address
  Owner   Tenant                          Occupied  %

Sprinklers?

Year Built

Construction Type

Number of Stories

Number of Basements

Square Footage

Burglar Alarm

Building Value $ Contents  $

Other Property (Specify)

  If no more property, jump to next section
Property / Premises Information 3
Street Address
  Owner   Tenant                          Occupied  %

Sprinklers?

Year Built

Construction Type

Number of Stories

Number of Basements

Square Footage

Burglar Alarm

Building Value $ Contents  $

Other Property (Specify)

Liability
Class of Business
Other
Annual Gross Sales $ (before taxes)
Number of employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested
Describe any claims you've
had in the past 5 years
Additional Comments