Language
English (US)
Spanish (Latin America)
Français
Italiano
German (Germany)
Pettigrew Agency
Commercial Intake Form
How did you hear about us?
*
Please Select
Ashlyne
Darren
Kiffany
Google
Facebook
Other Social Media
A Customer Referred Me
Newspaper Ad
Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
Name
*
First Name
Last Name
Name Of Business
*
Describe your business and what all it does. Please be detailed so that we can explain to underwriters as well as get you accurate supplemental applications to expedite the quote turn around.
*
When Was Business Established
*
/
Month
/
Day
Year
Date
Entity Type
*
Sole Proprietor, LLC, Corporation, Non-Profit, Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do we have permission to communicate via text with you at this number?
*
Yes
No
Business Physical Address (Note if home based use home address here)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address If different Than Above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Desired Coverage Start Date
*
/
Month
/
Day
Year
Date
What is your EIN?
*
What Is Your Estimated Annual Gross Revenue?
*
Do you have employees?
*
Please Select
Yes
No
What is your estimated annual payroll NOT including yourself?
Do You Have Any Business Autos?
*
Please Select
Yes
No
Does Your Business Serve Alcohol?
*
Please Select
Yes
No
Have You Ever Had Insurance On This Business Before?
*
Please Select
Yes
No
Does Your Business Have Any Property That Needs To Be Insured? Such as equipment, supplies etc.
*
Please upload current declarations page if available
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Any additional notes you would like us to know?
In connection with this application for insurance, Farmers and Pettigrew Agency partners/affiliates may review your and your spouse’s credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use third parties in connection with the development of your insurance scores based on data from traditional credit bureaus and the National Consumer Telecom & Utilities Exchange database.” Also, do you consent for Farmers and Pettigrew Agency partners/affiliates: (1) to access any available driving scores from a third party based on vehicle telematics data, (2) to use any consumer report information their affiliates might currently have for you for this transaction, and (3) to share consumer report information from this transaction with their affiliates to quote other products?
*
Yes, I consent.
Submit & Complete optional Life quote
Should be Empty: