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Hill & Usher does not sell or otherwise transfer any of its database information to other entities for the purposes of marketing to you.

 

Tell us about Yourself...
First Name
Middle Initial
Last Name
Title
Email Address
Email Address Confirm
First Name or Nickname
(salutation for email messages)
Telephone Area Code & Number Ext
Mobile Area Code & Number
Fax Area Code & Number
Business Website Address
Are you the final decision-maker concerning insurance coverage for your Company? Yes No

 

Physical Location of Your Business
Street Address
City
County
State
(Select One)
Zip Code
(+4 optional)
-
Do you operate your business from any other physical location? Yes No

 

Mailing Address
(if different from physical location above)
Street Address
City
County
State
(Select One)
Zip Code
(+4 optional)
-

 

Tell us about your Business...
Complete Legal Name
of Primary Insured Individual or Entity
Persons With Ownership Interest
List All Owners of the Business
Registered Trade Name
(DBA, etc.)
Legal Structure
(select one)

If Other Please Explain

Federal Employers Identification Number / Social Security Number

 

Business Operations & Experience
Years in Business
(under your current business entity)
Detailed Description of Operations

 


Other Coverage-Related Information
Desired Liability Limits
(per occurrence)
$1000000  $2000000 
Other
Annual gross sales
Total Annual Payroll
(not including owner(s))
Workers Compensation Insurance provided for all employees
(as required by law)
Yes No
Total Number of Employees
Do employees/others drive personal vehicles on your behalf Yes No
Number of Certificates of Insurance
(in a typical year-estimated)
Percentage of total business derived from website or internet this year

 

Additional Underwriting Information
(incomplete or inaccurate information will delay your quote or disqualify you for coverage.)
Current Policy Expiration Date (MM/DD/YYYY)
Current Insurance Carrier
Current Annual Premium
Total dollar value of claims (all types) during the last five years
Number of claims in excess of $500 during last five years
Please briefly describe each claim
(Include Dates & Amounts Paid)
Since the occurrence of claims, what changes in operations or safeguards have been instituted to protect from future loss
Additional Coverage Requests
Requested Policy Effective Date: (MM/DD/YYYY)
(after your acceptance of our quotation and carrier approval of your application)

How did you first come to learn about Hill & Usher?

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If you found us via a search engine,
what terms did you enter?

Other Comments/questions

By submitting this request, you attest to the accuracy and completeness of the information provided. You understand that no coverage is in force until a policy of insurance is approved and issued on your behalf. Hill & Usher will not be held responsible for coverages not available, coverages not requested by you, or limits not sufficient at the time of this submission.

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No application will be submitted or bound with the insurance carrier until you have accepted our quotation.

IMPORTANT INFROMATION REGARDING THE USE OF YOUR INSURANCE/CREDIT SCORE:
By submitting this request for a quotation, you hereby permit the agency, its employees, owners, and affiliated insurers (HILL & USHER, LLC) to use data contained within your "insurance credit score" as the basis for determining your eligibility for our products where permitted by law.  You understand that an unacceptable "insurance credit score" as deemed by our insurance carrier(s) may result in your ineligibility for coverage.  You agree to hold HILL & USHER, LLC harmless from fault or liability in the event that your "insurance score" is unacceptable to the carrier(s), even if the information contained therein proves inaccurate in any way.
Due to privacy concerns and the proprietary nature of "insurance scores," HILL & USHER, LLC will not know the details of your "insurance score."  In compliance with the Fair Credit Reporting Act http://www.ftc.gov/os/statutes/fcra.htm, you have the right to request information about your "insurance score" or to dispute in writing the results of an unfavorable "insurance score."  Upon request, HILL & USHER, LLC will furnish you with contact information for the relevant credit rating bureau.  Your "insurance credit score" is a combination of your business or personal credit history, loss history, and other factors that may reasonably predict the likelihood of future claims.
If you have Questions/Problems with this form please email the webmaster or call our office at (602) 956-4220 between 8AM and 5PM Monday through Friday, Arizona time.
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Richard B. Usher,
Agency Principal
Hill & Usher
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Phone: (602) 956-4220 | Fax: (602) 956-4418