Commercial Intake Form
Please complete to the best of your ability. If you have any questions, please text/call me at 773-500-2727 or email me at sam@roseinsgroup.com
Submission Date
*
-
Month
-
Day
Year
Date
Contact Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name of the Business
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Full Name
*
First Name
Last Name
Owner's Date of Birth
*
-
Month
-
Day
Year
Date
Owner's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tax ID
If Applicable
Detailed Description of Business
*
Tell us what your business is all about! What do you do, who do you serve, where do you operate, and anything else that helps us understand your day-to-day. The more detail you can share, the better we can match your insurance needs.
Type of Ownership
*
Corporation
LLC
Partnership
Non-Profit
Sole Proprietor
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Year Business Formed
*
Annual Revenue/Sales
*
If this is a new business, just give us your best guess!
Years of Experience
*
How long have you been in a similar industry/role?
Annual Payroll
*
Specify Subcontractor and Employee Payroll. Put NA if Not Applicable
Number of Employees
*
Specify How Many Subcontractors and Employees
Liability Limits Requested
I recommend at least $1M/$2M
Has Your Business Had Any Claims in the Last 5 Years?
*
Yes
No
If So, Describe What Happened
Be sure to include Date of the Loss, How Much Was Paid Out, and if the Claim is Closed or Still Open
Do You Rent or Own the Building Where Business is Conducted?
*
Rent
Own
I work out of my home
Amount of Business Property Coverage
*
Inventory/Equipment/Tools
Business Income Coverage Desire
*
Yes
No
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Current Insurance Carrier
*
Put NA, if this is a new venture!
Current Premium
Sharing your current premium (monthly or yearly) helps us evaluate your coverage and identify potential savings or better options. We will tell you if you are getting a great deal!
Upload a Copy of Your Current Policy or Any Other Necessary Documents
Browse Files
Drag and drop files here
Choose a file
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Provide Any Other Details You Believe Would Be Helpful
We want to make sure we find you the coverage you want. Feel free to take this space to let us know what you are looking for in an insurance company. We will do our best to find it for you!
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