Commercial Quote Intake Form
April Dunning Agency, LLC.
Name of Business Entity
Name of Primary Insured
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
FEIN#
No hyphens
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth (Primary Insured)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Annual Revenue (past or projected)
Describe daily operations and % of time for each
# of Full-Time Employees
Payroll Amount Annually
Years of Experience in this field
Prior Carrier, # of years insured
Desired Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Business Property & Value for Each
Claims History
Current Declaration Page
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of
Current Loss Runs Report
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Other Coverages
Commercial Auto
Workers Comp
Umbrella
Inland Marine/Contractor's Equipment
General Liability Only
Bonds
Professional Liability
Notes/Additional Info
Submit
April Dunning Agency,LLC.
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