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Business Insurance
1
Which state
do you need insurance in?
*
This field is required.
Florida
Illinois
Indiana
Michigan
Pennsylvania
Wisconsin
Other
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2
What's
your name?
*
This field is required.
First Name
Middle Name/Initial
Last Name
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3
{name:first}, nice to meet you! What's the
name of the company?
*
This field is required.
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4
What's your role
with {nameofcompany}?
*
This field is required.
CEO/Founder
Partner
Executive
Administration
CEO/Founder
CEO/Founder
Partner
Executive
Administration
(This is your relationship to {nameofcompany})
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5
Which
type of legal entity
is it?
*
This field is required.
Select the type of business organization.
Sole Proprietorship
Limited Liability Company
S Corporation
Partnership
C Corporation
Not For Profit
Joint Venture
Trust
Don't Know
Other
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6
When did {nameofcompany} start
?
*
This field is required.
Provide a date.
-
Month
Day
Year
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7
What's the
Tax ID or EIN?
This is the nine-digit company identification number issued by the IRS.
Only numbers required
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8
What's the
business address?
*
This field is required.
(This information is needed to provide an accurate quote. It must be a place you can receive mail; include unit number if applicable; the blue map button may help if you're there.)
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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9
What's your
business email address
?
*
This field is required.
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10
What's your
business phone number?
*
This field is required.
Ex: (312) 555-5555
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11
Which types(s) of insurance
are you interested in?
*
This field is required.
(select all that apply)
Business
Key Person
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12
Selection Temp
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13
When would you like your insurance policy to
start?
/
Month
Day
Year
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14
What is the
industry
the business is in?
*
This field is required.
Choose the best option. If none, select other.
Agriculture/Forestry/Fishing
Art/Design/Media
Banking/Finance/Real Estate
Business/Sales/Office
Construction/Energy Trades
Education/Library
Engineer/Architect/Science/Math
Government/Military
Information Technology
Insurance
Legal/Law Enforcement/Security
Maintenance/Repair/Housekeeping
Manufacturing/Production
Medical/Social Services/Religion
Personal Care/Service
Restaurant/Hotel Services
Sports/Recreation
Travel/Transportation/Warehousing
Other
Agriculture/Forestry/Fishing
Art/Design/Media
Banking/Finance/Real Estate
Business/Sales/Office
Construction/Energy Trades
Education/Library
Engineer/Architect/Science/Math
Government/Military
Information Technology
Insurance
Legal/Law Enforcement/Security
Maintenance/Repair/Housekeeping
Manufacturing/Production
Medical/Social Services/Religion
Personal Care/Service
Restaurant/Hotel Services
Sports/Recreation
Travel/Transportation/Warehousing
Other
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15
What is the
nature of the business?
*
This field is required.
Choose "other" for if nothing matches.
Academic/Research
Apartments
Condominiums
Contractor
Institutional
Manufacturing
Office
Restaurant
Research
Retail
Service
Wholesale
Other
Academic/Research
Apartments
Condominiums
Contractor
Institutional
Manufacturing
Office
Restaurant
Research
Retail
Service
Wholesale
Other
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16
Would you like to
upload documents
to speed up the process?
*
This field is required.
(If applicable, you may upload
insurance "declaration pages"
for previous coverages and effective dates.)
YES
NO
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17
Upload (1)
business insurance declarations
and/or (2)
all other pertinent business documents.
(This upload system is secure and you may upload all available documents here.)
Drag and drop files here
Select files to upload
Upload Insurance Docs
Cancel
of
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18
Who else should be ADDED
to the policy?
*
This field is required.
(List all people and/or companies that should be listed on the policy and click ADD. If none, type "NA" then click ADD then click FORWARD.)
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19
Describe The Business!
*
This field is required.
What products and/or services do you offer? Be as descriptive as you can to help us assess the risks properly! We'll follow up.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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20
What is your anticipated
annual revenue?
*
This field is required.
How much will you do in sales? Best guess is fine!
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21
Any business-related
accidents, incidents or claims
in the last five years?
*
This field is required.
Select
all
issues from the
last five years.
If none, select "
None
."
None
Bodily Injury
Property Damage
Fire/Smoke
Wind/Hail
Theft/Vandalism
Water Damage
Liability/Lawsuit
Other
None
Bodily Injury
Property Damage
Fire/Smoke
Wind/Hail
Theft/Vandalism
Water Damage
Liability/Lawsuit
Other
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22
Which
business insurance features
would you like?
Select
all
desired
coverages or features.
We'll recap later.
Scheduled business personal property
Home Computer/Smart Device
Cyber Liability
Identity Theft Protection
Other
Scheduled business personal property
Home Computer/Smart Device
Cyber Liability
Identity Theft Protection
Other
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23
When would you like your insurance policy/policies to
start?
/
Month
Day
Year
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24
Will the key person insurance be for
you and/or some other person/people?
*
This field is required.
(select all that apply)
Me
Other(s)
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25
{name:first}, what's your date of birth?
*
This field is required.
(Required for insurance underwriting)
/
Example: 09/30/1963
Month
Day
Year
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26
Please select a
gender?
*
This field is required.
(Required for insurance underwriting)
Female
Male
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27
What's your
height & weight?
*
This field is required.
(required for life insurance underwriting; ex: 5'7", 170 lbs)
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28
List all
Medical Diagnoses
and
Prescriptions
taken in the last five years.
(required for life insurance underwriting; example: mild hypoglycemia, metformin 55 mg/daily)
Add medical diagnoses and prescriptions if any.
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29
Type your colleague(s)'
Applicant Details Here.
(List all people who should be listed and click ADD. When done, click FORWARD.)
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30
Which
special Key Person insurance features
would you like?
Select
all
desired
coverages or features.
We'll recap later.
Basic Mortgage Protection
Cash Value-Building
Waiver of Premium
Accelerated Death Benefit
20-Pay
Long Term Care Rider
Spouse or Child Term Rider
Cash withdrawals and loans Return of Premium
Guaranteed Death Benefit
Guaranteed Purchase Option
Final Expense
Other
Basic Mortgage Protection
Cash Value-Building
Waiver of Premium
Accelerated Death Benefit
20-Pay
Long Term Care Rider
Spouse or Child Term Rider
Cash withdrawals and loans Return of Premium
Guaranteed Death Benefit
Guaranteed Purchase Option
Final Expense
Other
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31
Email address of designated Risk Specialist (Skip if you don't know):
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Should be Empty:
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