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Getting Started with Business Insurance

Please make sure you fill out everything to the best of your knowledge as everything affects carrier choice and premium cost. Thank you, Philip Miles / CA Lic# 0K93165 AZ Lic# 17963684
When do you need coverage to start? *

MonthDayYear
Date
Who Referred you?
if you are an insurance agent, please type your name here :)
Business Owner Contact Information

Let's get to know you :)
Legal Name*

First NameLast Name
Date of Birth *
Cell Phone #*

Area CodePhone Number
Email*
example@example.com
What type of entity are you?*
Legal Entity Name*
What is your F-EIN number?
If none, please skip.
Business Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing the same as your business address?*

YESNO
What is the location of the business?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tell Us About Your Business
Describe how your business makes money and/or it's purpose:*
What is the reason you are searching for a new policy with us? *
Examples: Current cost went up to....., New business, Past policy lapsed on...., Need just general liability, need a full business owners policy, Need workers comp etc.
Business Website:
If you have a DBA, what is it?
What year did you start your business? *
E.G. 2007
How many years of experience do you have in this industry?*
In this specific industry you need coverage for
Is your business currently insured with an active policy?*

YesNoNo - New Business Venture
Does your business own any structures or buildings?*

YesNo
What year was your building built?*
As close as you can to the date as this is a rating factor
Building Square footage you occupy*
As close as you can estimate
What is the builiding you occupy construction type? *
E.G. Wood frame, Masonry, Steel
To best of your knowledge what year was the plumbing updated?   Year*
To best of your knowledge what year was the electrical updated?   Year*
To the best of your knowledge what year was the roof updated?   Year*
How much inventory does your business have?(products ready to sell)*
How much does your inventory cost?
How much equipment/business property do you have?*
If your business were to burn down, how much would all your business equipment or property cost to replace? i.e. laptops, desks, kitchen, tools, etc...
Do you have any W2 employees?*

YesNo
How many employees?
Please specify how many part time and how many full time
What is your monthly payroll?
What is your gross annual revenue? *
If you're a start up, please PROJECT the annual revenue instead.
Provide any other details about your business you feel to be important for insurance:
Have you received any other quotes for this business yet?*

Yes - (if so, please let us know)No
Current Quotes

Cancelof
Do you have any cars that are registered to the business?*

YESNO
Please provide all Driver's full name, date of birth and driver license # and state.
Please provide all vehicles' information.
Upload any insurance requirements you've been provided

Cancelof
Should be Empty:

Getting Started with Business Insurance

Business Owner Contact Information

Tell Us About Your Business