Request a Quote - InSource Insurance Group

Company Name(Required)

Subsidiaries ( if any )

Your First Name(Required)

Your Last Name(Required)

Your Phone Number(Required)

Company Phone Number(Required)

Your Email(Required)

Website Address (if applicable)

Ownership Information (for each company if more than one)(Required)

Name of owners, title, ownership percentage, and if you are included into workers comp, please include your salaries.

Date Business started

MM slash DD slash YYYY

Federal Tax ID #(Required)

(or SS # for Sole Proprietors)

Please provide a detailed description of your operations (attach additional pages if needed).(Required)

(attach additional pages if needed).

Attach additional pages

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 50 MB.

Please describe in detail your hiring practices, safety information, and drug testing methods.(Required)

(attach additional pages if needed).

Attach additional pages

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Please include copies of your safety program, employee manuals, and any brochures that you have. (InSource can help you develop these practices and procedures if requested)

Are you currently insured?(Required)

Yes

Attach prior certificates of insurance, upload as many as 5 documents.

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 5.

Attach prior certificates of insurance, upload as many as 5 documents.

Preferred Form of Contact(Required)

Phone

What kind(s) of quote(s) can we help you with? (Select all that apply)(Required)

Workers’ Compensation

Commercial General Liability

Commercial Auto

Commercial Umbrella / Excess Liability

Commercial Property

Commercial Inland Marine (mobile property)

Motor Truck Cargo

Control of Well Insurance

Employment Practices Liability Insurance (EPLI)

Cyber Liability Insurance

Surety Bonds (keep all fields below in one screen/workflow)

Risk Control Services

Employee Benefits (Health Insurance, Life Insurance, Dental Insurance, Vision Insurance, Etc)

Personal Insurance (Home, Auto, Etc)

Other (please explain)

Number of Part time employees(Required)

Please enter a number from 0 to 99999.

Number of Full Time employees(Required)

Please enter a number from 0 to 99999.

Which states do you have employees working in?(Required)

Please list each state, separated by a comma. give example in text – Example: Texas, New Mexico

Please list the payroll for each state listed above, by job type.(Required)

(Example: Texas Clerical = $50,000 annual payroll / Texas Roustabout = $50,000 annual payroll / New Mexico Trucking = $100,000 annual payroll.)

What were your annual gross receipts from last year?(Required)

What are your estimated annual gross receipts for this year?(Required)

What are your projected gross receipts for the next year?(Required)

What is the total square footage your business occupies?

How many vehicles do you have to insure ?

1 - 9

More than 9

Current Vehicle list(Required)

Year

Make

Model

VIN #

Cost ( new )

Click Here to Download the Vehicles Template

Current vehicle schedule for all vehicles and trailers (Year, make, model, VIN #, Cost new).

Accepted file types: pdf, xls, xlsx, doc, docx, csv, Max. file size: 50 MB.

Excel file preferred.

How many Drivers do you have ?

1 - 9

More than 9

Current drivers list(Required)

Name ( as it appears on license )

Date of Birth

State

Driver’s License Number

Type of License

Click Here to Download the Drivers Template

Current Drivers list (i.e. name as it appears on license, date of birth, state, driver’s license number, type of license)

Accepted file types: pdf, xls, xlsx, doc, docx, csv, Max. file size: 50 MB.

Excel file preferred.

How many buildings to do you occupy ?

1 - 5

More than 5

Do you need insurance coverage on any of your buildings or property inside?

Yes

Please fill the info for each building(Required)

Age Year Built

Square footage

Number of stories

Type (Brick, metal, wood frame, etc.)

Click Here to Download the Property & Land Locations Template

Contruction Type(Required)

Brick

Metal

Wood

Frame

Age Year Built, Square footage, number of stories, and type of construction for all buildings to be insured on the property policy. (Brick, metal, wood frame, etc.)

Accepted file types: jpg, png, pdf, xls, xlsx, doc, docx, csv, Max. file size: 50 MB.

Excel file preferred.

How many pieces of mobile equipment would you like insured?

1 - 10

10+

Please fill mobile Equipment details(Required)

Year

Make

Model

Serial number

Value

Click Here to Download the Mobile Equipment Template

Please provide your Current Equipment schedule (Year, make, model, serial #, value.)(Required)

Accepted file types: jpg, png, pdf, xls, xlsx, doc, docx, csv, Max. file size: 50 MB.

Excel file preferred.

What is the total value of the most expensive load that you might transport for others in one trip with one truck?(Required)

On average, how many trucks will be operating in the same geographical area at any given time? (within a 50-mile radius within each other).(Required)

What commodities or material are you hauling ?(Required)

list the top 5

How many wells would you be operating?(Required)

1 - 10

10+

Please fill the details of Wells(Required)

Well Type

Depth

Orientation

Value

Please provide us with a complete schedule of your existing wells and wells to be drilled; including well type, depth, orientation, and value.

Accepted file types: jpg, png, pdf, xls, xlsx, doc, docx, csv, Max. file size: 50 MB.

Excel file preferred.

Click Here to Download the Well Schedule Template

Number of employees(Required)

Estimated annual revenue(Required)

What type of bond are you needing?

Oil and Gas related

Other

I’m not sure

Are you needing a P-5 Bond for the Texas Railroad Commission (a blanket performance bond)?(Required)

Yes

I need a different type of oil/gas bond.

Do you carry Property and Casualty Insurance on your wells / company?(Required)

Yes

Are you just starting up and needing a bond in order get your business going?(Required)

Just starting new business

Established business

Other

Click Here to Download the BOND Authorization to obtain Credit Report Form Click Here to Download the Bond Supplemental Information Fill-able Form Click Here to Download the Bond Personal Financial Statement

Please fill out these apps and submit them

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, xlsx, Max. file size: 50 MB.

Disclaimer: We normally prefer to write bonds in conjunction with property and casualty insurance of our customers. For those that we help with oil and gas bonds only, we require a $1,000 fee in addition to the cost of the bond. Other fees may apply for non-oil and gas related bonds.(Required)

I agree and want to continue.

What type of Personal Insurance Coverage are you Needing? Select all that apply.

Home

Dwelling

Renters

Auto

Boat

RV/ATV

Umbrella

Other, please explain

What Personal Umbrella Limit would you like to carry?(Required)

$1 mil

$2 mil

$5 mil

$10 mil +

(Others) Please Explain(Required)

Please explain your requirement(Required)

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