Generic Commercial Intake Form

1

Your first and last name?* This field is required.

First Name

Last Name

2

DateTime

3

Submission Counter

4

What is the name of your business?* This field is required.

5

Email* This field is required.

example@example.com

6

Phone Number* This field is required.

Area Code

Phone Number

7

What is the best way to reach you?* This field is required.

Phone

Email

No preference

8

How did you find us?* This field is required.

Word of mouth/referral

Found us online (Google, Yahoo, Facebook, etc.)

Print advertisement

Radio ad

9

What state is your business in?

10

Is this for a new or existing business?* This field is required.

New business

Existing business

12

Business entity's EIN number?

13

If you have a website, list its address below:

14

Number of employees?* This field is required.

15

Estimated annual payroll amount:* This field is required.

16

Years in business?* This field is required.

17

Total Revenue?* This field is required.

18

Do you currently have insurance?* This field is required.

YN

19

Who is your current insurance carrier?* This field is required.

20

How many years have you been with your current insurance carrier?* This field is required.

21

Any claims within the past 3 years?* This field is required.

Yes

No

Unsure

22

No problem. Please give a brief summary of the claim(s):

23

Estimated total annual premium for your current insurance?* This field is required.(Choose "less than $10,000 if you have no current insurance policy in place.)

Less than $10,000

$10,000 - $49,999

$50,000 - $99,999

$100,000+