Request for Quote for 
Business Insurance

Note: Insurance Quotes are for Maryland 
and Virginia Businesses Only.

Here is your opportunity to get a free, no-obligation business insurance quote. Just follow the instructions below and when you have completed the form press the submit button. Your request will be handled by one of our staff members as soon as possible.

Instructions: Please complete as much of the form below as possible. We do not require that you complete all the information below, but please complete as much information as you can for the most accurate quote.

If you prefer, you may phone our office at 301-831-8802


Personal Information

Name  
Address  
City     
State  
Zip  
Email Address  
Home Phone     
Work Phone  
Fax  
Contact Me Via:  (please select from list below)
First Choice  

 

 
Second Choice  

Current Business Insurance Information

Current Business Insurance Carrier
Expiration Date
 

Business Information

Name of Business
Business Address
City State Zipcode
Contact Person
Phone
Describe Type of Business

Does your business occupying a building? Yes   No
If yes, is this building  owned by you   rented/leased

Number of Employees
Annual Sales
Annual Payroll
Business Type
   

Have you submitted any claims in the past five years?  Yes   No
If so, please describe (include dates of loss and amounts)

Comments / Remarks

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Kelly & Associates is licensed to conduct business in Maryland and Virginia.
The information on this site is a solicitation to conduct business only in
the aforementioned states of authority.

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