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Do You Qualify for an 831(b) Plan?
Please complete this assessment to see if you may qualify to strengthen your business through an 831(b) Plan.
13
Questions
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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+
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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
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3
What are 3 of your most concerning risks?
*
This field is required.
Audit
Brand Protection
Business Interruption
Credit Default
Data Breach
Directors & Officers
Dispute Resolution
Key Employee Loss
Political Risk
Professional Liability
Recalls
Representations & Warranties
Supply Chain Interruption
Warranties and Protection Plans
Other
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4
What is the organizational structure of your business?
*
This field is required.
LLC
C-Corp
S-Corp
Sole Proprietorship
Other
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5
Where are you located?
*
This field is required.
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)
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)
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6
Please provide your company URL or explain what your company does
*
This field is required.
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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
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8
Please fill in your first and last name
*
This field is required.
First Name
Last Name
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9
Please enter a valid phone number
Please enter a valid phone number.
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10
Please enter a valid email address
*
This field is required.
example@example.com
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11
Preferred Contact Method
*
This field is required.
Phone
Email
Either
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12
How did you hear about us?
*
This field is required.
online search, specific podcast name, YouTube video, advisor, referral, etc.
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13
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14
Please verify that you are human
*
This field is required.
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15
Lead + Contact Record Type
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16
Lead Type
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17
Lead Source
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18
Created from DYQ Jotform
Yes
No
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19
Sync with Salesforce
YES
NO
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