Row rect Shape Decorative svg added to top Row rect Shape Decorative svg added to bottom Commercial Insurance Quote Request Thank you for the opportunity to earn your business! Are you a current My Insurance Group client?(Required)Select an optionNo, I will be a new clientYes, I am a current clientYour Name(Required) First Last What is the legal name of your business entity?(Required)What is your relationship to the business?(Required)Is your DBA name different from your legal entity name?Select an optionNoYesYour DBA (Doing Business As) nameYour Federal EIN/Tax ID Number (if you have one)Format: XX-XXXXXXXYour Preferred Phone Number(Required)Your Preferred Email(Required) Your mailing/correspondence address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What are you looking for help with? Check all that apply:(Required) Everything Workers Compensation Business Owner Package Policy Commercial Auto General Liability Commercial Umbrella Commercial Property Bonds, Equipment, Other, Etc. What effective date do you want for your new insurance program?(Required) Month Day Year What is your main reason for reaching out to us now?Select an optionI am shopping my upcoming renewalUnhappy with my current agent/brokerUnhappy with recent claim experienceJust curious what My Insurance Group can do for meLocation InfoIs your location address different from your mailing address?(Required)Select an optionNo, they are the sameYes, my location and mailing address are differentWhere is your business located?(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Briefly describe your business operations:(Required)What is your projected revenue for the upcoming 12 months?(Required)How many employees does your business have?Select an option01-45-1011-50More than 50 employeesDoes your business own or lease your physical location?Select an optionLeaseOwnDoes your business OWN or LEASE any automobiles or mobile equipment?Select an optionNo, we don't OWN or LEASE vehicles of mobile equipmentYes, we OWN vehicles or mobile equipmentYes, we LEASE vehicles or mobile equipmentYes, we both OWN and LEASE vehicles or mobile equipmentWrap upHow did you find out about My Insurance Group? Personal Referral Local event Facebook group/post Google YouTube ChatGPT Word of mouth Name of person who referred youPlease share any remaining info/details that will help us deliver you a great experienceYou may upload files hereIt is extremely helpful for this process if you're able to share current policy documents with us at the beginning. Since we are an independent brokerage, our loyalty is to you, and not any particular company. Drop files here or Select files Max. file size: 5 MB, Max. files: 5. Authorization(Required) I agree to the followingBy submitting this request you are authorizing My Insurance Group, LLC, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. My Insurance Group, LLC is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, Ai outreach, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.
