Please select the type of quote you would like to receive from the drop-down menu.  A Penta representative will contact you after you submit the form.

Commercial forms can also be downloaded here, and sent to Penta for a quote.

ehealth
Personal Auto Quote   (back to top)
Name
 		Email Address
Home Phone
 Work Phone
Mailing Address
City 
 State
 Zip
Policy Effective Date (MM/DD/YY)
Vehicle Information:
Year
 Make/Model
 Date Purchased (MM/DD/YY)
Driver Information:
D.O.B (MM/DD/YY)
 Driver #
 State
 Years Lic.
 Sex

 Marital Status

Has the driver had any prior accidents or violations?     Yes  No
Accident/Violation Date(s) Accident/Violation Details
1
2
3
Usage:

Pleasure     Business     Car Pool     Miles Each Way to Work 
Coverages/Premiums:
Single Limit Liability $ each accident

..........................................................................................................................................................
Bodily Injury Liability
$ each person $ each accident

..........................................................................................................................................................
Property Damage Liability $ each accident

..........................................................................................................................................................
First Party Benefits
Tort:  Full     Limited
$ Medical $ Weekly Loss
$ Funeral $ Accidental Death

..........................................................................................................................................................
Uninsured Motorists
Stacked
$ each accident
 
 Non-Stacked
$ each accident $ each person

..........................................................................................................................................................
Comprehensive $ Deductible

..........................................................................................................................................................
Collision $ Deductible

..........................................................................................................................................................
Towing & Labor $  

..........................................................................................................................................................
Additional Coverages/Endorsements:

Homeowners Quote   (back to top)
Name
 		Email Address
Home Phone
 Work Phone
Mailing Address
City 
 State
 Zip
Coverages/Limits of Liability:
HO Form
$ 		Dwelling
$ 		Personal Liability
$ 		DED (Type & Amount)
All Peril $
Wind Hail $
Theft $
Hurricane $
Rating/Underwriting

Frame Masonry Masonry Veneer Aluminum Siding
Plastic Siding Asbestos Siding Fire Res

..........................................................................................................................................................
Year Built
 # Rooms
 Sq. Ft.
 # Apts

Market Value
$
Replacement Cost
$
..........................................................................................................................................................
Structure Type
Dwelling Apartment Condo Townhome Rowhome Seasonal

Usage Type
Primary Secondary Seasonal Farm COC UNOCC Vacant

..........................................................................................................................................................
Purchase Date
 Purchase Price

Workers Compensation Quote   (back to top)
Name
 		Email Address
Home Phone
 Work Phone
Company
Mailing Address
City 
 State
 Zip
Yrs. in Business Individual Partnership Corporation SubChapter "S"
Locations
Street City State Zip
1
2
3
Proposed Effective Date (MM/DD/YY)
 Proposed Expiration Date (MM/DD/YY)
Rating Information

State LOC Class
Code		 Categories, Duties, Classifications No. of
Emp(s)		 Estimated
Annual
Renumeration		 Rate Estimated
Annual
Premium
$ $
$ $
$ $
$ $
Prior Carrier Information
Year Carrier Policy Number
Nature of Business/Description of Operations

Business Owners Policy Quote   (back to top)
Name
 		Email Address
Home Phone
 Work Phone
Company
Mailing Address
City 
 State
 Zip
Individual Partnership Corporation
Limited Corp Joint Venture Other
GL Code
 SIC Code
 Federal ID#
Contact for Inspection
 Phone
Credit Bureau Name
 ID #
Nature of Business

Office Retail Apartments Restaurant
Service Wholesale Condominiums Contractor
Years in Business
 Class Code
 Rate #
 Rate Group
Number of Employees
 Hours of Operation
Annual Sales Receipts
$ 		Total Payroll
$

Description of Operations/Occupancy
Premises
Mailing Address
City
 State
 Zip
Interest
Owner   Tenant		 Year Built
 Square Feet
Property
Building Building
Limit $ Deductible $
Personal Property Personal Property
Limit $ Deductible $
.........................................................................................................................................................
Construction Type
 # Apt. Units
 # Stories
.........................................................................................................................................................
Building Improvements
Wiring Year
 Roofing Year
 Plumbing Year
 Heating Year
 Roof Type
Liability

Combined Single Limit  $
Prior Policy/Loss History
Previous Carrier
 Policy Number
Total Premium
 Expiration Date
 # Losses Last 3 Years

Description of Losses

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