Do You Qualify for an 831(b) Plan?

1
What is your company's approximate gross revenue?* This field is required.If you have more than one company please combine total gross revenue.
Under $500,000
$500k - $1M
$1 - $5M
$5 - $10M
$10 - $20M
$20M+
2
Which industry is your company in?* This field is required.
Construction
Dental or Medical
Manufacturer
Professional Services
Property Manager
Retail
Self-Storage
Service Industry
Technology
Other
3
What keeps you up at night?* This field is required.
Audit Assurance: Costs of being audited by IRS, OSHA, SEC, FDA, or other agencies
Brand Protection: Negative media damaging your brand’s reputation
Business Interruption: Natural disasters shutting down operations
Coinsurance Penalty: Gaps in coverage due to insurance policy clauses
Contract Default Liability: Unreliable vendors or contractors not fulfilling obligations
Credit Default: Clients failing to pay their invoices
Custom Warranty: Honoring warranty issues on products or services
Data Breach Liability & Loss of Income: Cyberattacks, phishing, and ransomware attacks that are exclusions or uninsured
Deductible Reimbursement: Financial strain from high insurance deductibles on claims
Directors & Officers: Personal liability for board members facing lawsuits
Dispute Resolution: Legal battles with employees, customers, or contractors
Employer Liability Interruption: Employee lawsuits over harassment or discrimination
Key Employee Loss - Accident & Critical Illness: Losing a key employee to illness or injury
Political Risk: Government actions causing unexpected financial loss
Professional Liability: Liability gaps or denied coverage for your profession
Representations & Warranties: Deal fallout due to breached promises
Supply Chain Interruption: Supply chain breakdowns from disasters or civil unrest
Third-Party Business Interruption: Critical vendor issues or bankruptcies disrupting business
Other
4
What is the organizational structure of your business?* This field is required.
LLC
C-Corp
S-Corp
Sole Proprietorship
Other
5
Where are you located?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Overseas (Not in the United States)
6
Please provide your company URL or explain what your company does* This field is required.
7
How long has your company been in business?* This field is required.
Less than 1 year
1-3 years
3-10 years
10+ years
8
Please fill in your first and last name* This field is required.
First Name
Last Name
9
comet_token
10
Please enter a valid phone numberTHIS IS OPTIONAL. By providing a telephone number and submitting this form you are consenting to be contacted by SMS text message. Message & data rates may apply. You can reply STOP to opt-out of further messaging.
Please enter a valid phone number.
11
Please enter a valid email address* This field is required.
example@example.com
12
Preferred Contact Method* This field is required.
Phone
Email
Either
13
How did you hear about us? * This field is required.
online search, specific podcast name, YouTube video, advisor, referral, etc.
14
How did you hear about us?* This field is required.
Please Select
Please Select
Online Search
Podcast
Event
Referral/Word of Mouth
News Article
Social Media
Other
15
16
Please verify that you are human* This field is required.
17
Lead + Contact Record Type
18
Lead Type
19
Lead Source
20
Created from DYQ Jotform
YesNo
21
Sync with Salesforce
YESNO
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