Business Insurance Intake Form

Business Insurance Intake Form

Please complete the information to the best of your ability, so that we can provide you with the best valued market estimates and coverage recommendations!
Today's Date

MonthDayYear
Date
How did you hear about us?
What is the referring person's Name?
Name
Name of Business

Entity NmeDBA
Entity Type
Other Type
Business Owner's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Do you have a Partner or Spouse you are working with?

YesNo
Business Partner / Spouse Name

First NameLast Name
FEIN (SS for Sole Prop)
When did the Business Start?

MonthDayYear
Date
Any prior Insurance?

NoYes
Prior Carrier Name?
Has their been a lapse in coverage?

NoYes
Reason for Lapse?

Non PaymentNon RenewalCould Not AffordBusiness shut down and is now restartingOther Reason
Reason for Shopping?

Non RenewalPremium IncreaseCoverageServiceOther
Has the business had any losses in the last 5 years?

YesNo
Additional Details on any of the above:
What services or products does the business provide?
Annual Revenues?
* Not needed if they are only looking for premise liability.* Who are the businesses top 5 clients and the percent revenue from each?
Number of W2 Employees?
FT & PT
Total Annual Payroll?
Any 1099 Employees & their Payroll?
Do you currently have a Worker's Compensation Policy?

YesNo
Open to WC?

YesNo
Are there any leased employees?

YesNo
Do all employees have the same role/duties/positions?

YesNo
If Multiple roles: Class Types (Roles), # of Employees, & Payroll for each Class Type
Owners/Officers/Members Names?
Owner's Payroll?
Do you want to exclude or include coverage for owners?

ExcludeInclude
Any Work Comp Losses in the last 5 years?

YesNo
Additional Info.
Does the business own/need Commercial Autos?

YesNo
Vehicle List: VIN #s, Year, Make & Model, Vehicle BODY TYPE & Garaging Addresses for each vehicle?
Driver List: First & Last Names, DOB, DL#, Married, Which vehicle they drive?
Additional Coverage Needs:
Business Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business PHYSICAL ADDRESS: (If different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own or lease building / space?

LeaseOwn
What is the square footage of the space you occupy?
Square Feet
Is the Entity that operates the business the same Entity that owns the Building?

YesNo
Do you need the building insurance as well or is that already covered?

Yes, also need Building InsuranceNo, it is covered at this time. Just shopping the business operations part.
Copy and Paste the link below in another browser windo to also complete the information we will need to insure the building, once you have submitted this form.
https://form.jotform.com/240424479499166
Contact Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Great. Underwriters will also want to see a copy of your 5 year loss history for each line of business (or as far back as business has existed) before issuance, and it can take a whlie for the current carrier to send them, so we recommend placing an order for them as soon as possible.
If you have your current declaration pages, that can also help underwriters more competetively price a new proposal for you.
The more information that we can provide the insurance carriers with, the lower the risk you come off to them and the more willing they are to give favorable pricing.
This form was completed by:

First NameLast Name
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