Commercial Insurance - Step 1
Please complete the intake form below to the best of your ability. We'll shop our markets and present the best option based on the data you provide us. If you are a start-up and/or new business venture, start with this form as well. Thank you, Aldo Bermudez / CA License #0i60526
Desired Effective Date
*
Business Entity Name
*
Contact Name
*
This will serve as the inspection and primary contact.
Contact Phone Number
*
This will serve as the inspection and primary contact.
Format: (000) 000-0000.
Email
*
example@example.com
Entity Type
*
Sole Proprietor
LLC
INC
Trust
Partnership
Other
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Building Information
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Annual Rent Roll (aka Gross Rental Income)
*
Year Built
*
Total Number of Units
*
Total Square Footage
*
Number of Buildings at Location
*
Check All that Apply:
*
Senior Housing (Medical or Non-Medical)
Student Housing
Assisted Living
On-Site Property Manager
Off-Site Property Manager
Security Cameras
Pets Allowed
Swimming Pool or Jacuzzi
What Year Was The ROOF Last Replaced/Updated?
*
Brand New - This Year
2-5 Years Old
5-10 Years Old
10-20 Years Old
Older than 20 Years
What Year Was The PLUMBING Last Replaced/Updated?
*
Brand New - This Year
2-5 Years Old
5-10 Years Old
10-20 Years Old
Older than 20 Years
What Year Was The ELECTRICAL Last Replaced/Updated?
*
Brand New - This Year
2-5 Years Old
5-10 Years Old
10-20 Years Old
Older than 20 Years
What Year Was The HEATING Last Replaced/Updated?
*
Brand New - This Year
2-5 Years Old
5-10 Years Old
10-20 Years Old
Older than 20 Years
Type of Parking?
*
Detached Garage / Carport
Subterranean
Tuck Under
Parking Lot
Other
Fire Sprinklers Inside the Building?
*
Yes
No
Prior Carrier & Claim History
Name of Current Carrier
*
Prior Loss History in the last 5 years?
*
No
Yes
Upload Loss Run and Prior Policy Declaration Page
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Ignore if this is a new purchase or new venture.
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