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Business Insurance - New Client
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Are you currently working with any Agents at Canyon State Insurance? If no, put N/A
*
Enter Agent Name here or put N/A
Business Owner Name
*
First Name
Last Name
Business Owner - Date of Birth
*
Date of Birth
E-Mail
*
Email
Phone Number
*
Format: (000) 000-0000.
Name of Business
*
Company Name
Nature of Business/Operations
*
Use as many details as possible - avoid one word answers
Website (if applicable)
Website Address
FEIN / Tax ID:
*
Numbers only - No dashes
Physical Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Needs
Please Select All Insurance Products You Want a Quote On:
*
General Liability
Workers Compensation
Commercial Property
Inland Marine
Commercial Auto
Professional Liability / E&O
Other
Total Sales
*
Total Payroll
*
Number of Employees
*
Years in Business
Any Losses (if yes, please specify which insurance line and amount)
*
Other Insurance Interests:
Business Health
Business Life Insurance
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Commercial Auto
Upload Excel with Vehicle & Driver List, or fill out below sections
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of
Rows
Year
Make
VIN
Cost New
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Rows
Name
Date of Birth
License #
State
Driver 1
Driver 2
Driver 3
Driver 4
Driver 5
Requested Auto Liability Limits
example: 300,000 Combined Single Limit
Hired / Non-Owned Coverage
Yes
No
I'm not sure
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Commercial Property
Location(s) Address
List All Locations Occupied
Location Owner
Please Select
Leased
Owned
Personal Residential
Sqaure Footage Occupied
Ex: 3,200 sq. feet
Construction Type
Frame, Masonry, Metal, etc.
Building Property Value
Value of coverage needed for each building
Business Personal Property
Value of business items inside the building
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Workers Compensation
Employee Payroll Information (do not include Owner's payroll)
Rows
Job Type
# of Employees
Estimated Salary
State(s)
Payroll 1
Payroll 2
Payroll 3
Payroll 4
Company Ownership Information
Rows
Name
Salary
Ownership %
Included or Excluded in Coverage?
Owner 1
Owner 2
Owner 3
Desired Limit: Each Accident / Each policy / Each Employee
1m / 1m / 1m
500k / 500k / 500k
100k / 500k/ 100k
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Optional - Upload any existing policy documents, 5 year loss run, or relevant files
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