Commercial Insurance Policy Request

Commercial Insurance Policy Request

Please complete as much as possible for the best results
List the Agents name you prefer to work with
If unknown, please enter "Lisa"
Your Company Name *
Or your name if the business is not currently established
Tax ID Number *
If available
Website
If available
Your Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Percentage of ownership *
If not 100%, please provide names of additional owners and their date(s) of birth:
Please describe in detail your business*

Minimum 20 words.0/0
What is the most important thing you are concerned about regarding your business insurance?
How many years have you been in business? *
How many years experience do you have? *
Phone number *
Please enter a valid phone number.
Email*
example@example.com
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address if different
Any Additional Locations
Square Footage of your building/suite/warehouse *
If home based, type n/a
Do you, or will you:

LeaseOwn
Have you made any Tennant Improvements?
Dollar amount
Year Built
Type of Roof Materials (if known)
Does the building/suite have a working:

Sprinkler systemFire suppression systemBurglar alarmMonitored burglar alarmMonitored Fire Alarm
Number of Full Time Employees*
Including owner and all officers
Number of Part Time Employees *
Annual Gross Revenue*
Must be greater than $5,000
Total Annual Payroll with Owner*
Annual Payroll without Owner*
Required for workers comp if applicable
Amount of Business Property to operate your business? *
Dollar amount of desks, computers, shelves, display cases, freezers, cookers, etc. If none, type NA
Would you like insurance for your Business Property?*

YesNoNot sureNA
Amount of inventory for sale on average
Dollar amount
Any inventory subject to spoilage?
Dollar amount
Current Insurance Provider*
If none, type n/a
Desired Effective Date*

MonthDayYear
Date
Type of Insurance Requested/Required*

Commercial General Liability (GL)Workers CompensationCommercial AutoCommercial UmbrellaProfessional Liability (E&O)Commercial Real EstateTools & EquipmentKey Person Life Insurance
Current Auto Liability Coverage
Uninsured motorist coverage

YesNo
Deductible for Comprehensive and Collision
Commercial Umbrella Coverage Required
Minimum is $1,000,000.
What else would you like to share to help us prepare the best policy for you?
If needing Commercial Auto, please include all driver information here including driving license numbers
How did you hear about us? *
Feel free to upload your current policy or declaration pages if available

Cancelof
Thank you for choosing us to assist you with your insurance needs. We are excited to provide you superior service and value.

Dodge Insurance Agency

DodgeAgency@outlook.com

702-827-6007
Should be Empty: