Name: The RUOK Insurance Agency
Price range: $$

Facebook

This field is for validation purposes and should be left unchanged.

Unique ID

When do you want the policy, or policies, to start?*

What type of policy do you need?*

Additional policy types needed*

Check any additional policies that you need.

Workers Comp

General Liability

NA

Primary Insured Name*

Insured Date of Birth*

Email*

Work Phone

Mobile Phone*

SMS Consent

By checking this box, you consent to receive text messages from The RUOK Insurance Agency at the mobile number provided regarding your insurance inquiries, quotes, and policy updates and promotional/marketing messages. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

How were you referred to us?*

Business Information Continued

What is your total annual sales/revenue? (Gross)

What percentage of your sales are retail? %

Please enter a number from 0 to 100.

What percentage of your sales are wholesale? %

Please enter a number from 0 to 100.

Do you have employee(s)?*

Yes

No

Number of employees*

Employee Details*

Employee Name

Date of Birth (mm/dd/yyyy)

Hours Worked

Role / Status

Building and Property Information

My business location is*

Leased Property

Owned Property

Work From Home

Do you have more than 1 business location?*

Yes

No

Additional Location(s)

Location 2 is*

Owned

Leased

Location 2: Address*

Street Address Address Line 2 City State ZIP Code

Location 2: Square Feet

Add 3rd Location

Yes

Location 3 is*

Owned

Leased

Location 3: Address*

Street Address Address Line 2 City State ZIP Code

Location 3: Square Feet

Liability Limits (Optional)

What is the Liability limit requested?

Do you need any Business Personal Property coverage?*

Yes

No

Not sure, let's discuss

How much Business Personal Property coverage do you want?

Are you interested in Loss of Use / Business Income coverage?*

Yes

No

Not sure, let's discuss

Additional Insured

Do you have anyone that needs to be listed as Additional Insured?

Yes

No

Flooring Company

AFC

AFS

Challenge Financial

Nextgear Capital

Westlake Financial

Other

You may upload your additional insured documents using the upload field below.

Name of Flooring Company if not listed

Additional Insured Document(s)

You may upload up to 10 PDF documents. If you have more documents you can send them to your agent after they contact you.

Drop files here or

Accepted file types: pdf, Max. file size: 20 MB, Max. files: 10.

Claims Information

Have you had any claims or losses in the last 3 years?*

Yes

No

What was the date, amount paid, and description of each loss or claim*

Current Insurance

Has your business been cancelled or non-renewed in the last 3 years?*

Yes

No

Do you have ANY business insurance currently?*

Yes

No

Name of current insurance carrier?*

Expiration date of current policy*

Why are you looking for a new quote?

Current total insurance premium?

Current Policies

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 10.

Additional Comments and/or Current Policy Upload (Optional)

Any additional comments

Any Additional Documents

Drop files here or

Accepted file types: pdf, Max. file size: 8 MB, Max. files: 5.

Wrapping Up

What is the best time to call and discuss your quote?*

Please specify the best time to call*

Would you like a quote from a specific agent?

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge.*

Yes