Interstate - Business Onboarding Form

Business Onboarding Form
Monday.com Title
Sender Name
First Name*
Last Name*
Full Name
Policy
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are You A Current Interstate Customer?*

NoYes
Customer Type
Your Birthdate*

MonthDayYear
Date
Your Driver's License Number*
Phone Number*
Please enter a valid phone number.
Legal Business Name *Include Inc. or LLC if needed. (If you don't have a business name type "N/A")*
What Year Was The Business Started?*
Desired Effective Date of Coverage to Begin*

MonthDayYear
Date
Do you have an FEIN number?*

YesNo
FEIN Number*
Address of Business*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the above address the same as your Billing Address?*

YesNo
Address
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own or rent your space?*

OwnRent
Did you invest money into building out the space?*

YesNo
How much did you invest into the buildout?*
Replacement Value of Building*
Ex: $450,000
Value of Contents / Inventory*
Ex: $35,000
What does your business do or sell? (Explain what goods or services your business sells or provides).*
Ex: Coffee Shop
What are your total gross receipts for last year?*
Ex: $85,000
What do you expect the total gross receipts to be for this year?*
Ex: $123,000
Do you have business owned vehicles or trailers?*

YesNo
How many vehicles does your business own?*

12345
Please enter the Year, Make & Model, and VIN# for Vehicle 1
Ex: 2018 GMC Acadia - VIN# 123456789
Please enter the Year, Make & Model, and VIN# for Vehicle 2
Ex: 2018 GMC Acadia - VIN# 123456789
Please enter the Year, Make & Model, and VIN# for Vehicle 3
Ex: 2018 GMC Acadia - VIN# 123456789
Please enter the Year, Make & Model, and VIN# for Vehicle 4
Ex: 2018 GMC Acadia - VIN# 123456789
Please enter the Year, Make & Model, and VIN# for Vehicle 5
Ex: 2018 GMC Acadia - VIN# 123456789
If you have any additional driver's please list their Name, Date of Birth, and Driver's License Number.
Do you have W2 Employees?*

YesNo
What is the annual payroll for all employees?*
Ex: $44,500
Does The Business Have Any Prior Claims?*

YesNo
Please Describe The Claim(s):*
Do you want Umbrella Liability Coverage?*

YesNoI'm Not Sure - Provide Me More Details When You Provide Me A Quote
How much Umbrella Coverage would you like?*

$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000
Do you have Machinery, High Value Equipment, or Tools that leave your premises on a regular basis that exceed $2,500 in value per item?*

YesNo
Please enter a Description, the Manufacturer Name and Value of each item.*
Ex: Mini Excavator - Kubota - $34,000
Is there anything else you are concerned about insuring that was not listed in the questions above?
If you have any Photos or Policy Pages that you would like to upload for review please upload them here.

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