Business Intake Form

Business Intake Form

CRIA INTERNAL
Today's Date

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

MonthDayYear
Date
Name of Business

Entity NmeDBA
Entity Type
Other Type
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 does the business do? (Ask as many questions as needed so that YOU understand what they do.)
Annual Revenues?
Who are the businesses top 5 clients and the percent revenue from each?
Number of W2 Employees?
FT & PT
Total Annual Payroll?
Number of 1099 Employees & Payroll?
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 into a new window this link:
https://form.jotform.com/240424479499166

Submit this form, and also complete the next form for the Building information.
Intake Form completed by:

First NameLast Name
Should be Empty: