Business/Contractor Insurance Intake Form

Business/Contractor Insurance Intake Form

Tell us about your business and contracting requirements so we can best support your specific industry.
Thank you for choosing to work with our agency!
We truly appreciate the opportunity to work with you. This short form will help us better understand your needs so we can provide personalized coverage options that fit your lifestyle or business.

Your information is secure and will only be used for quoting and communication purposes. You can learn more about how we handle your information, by reading through our privacy policy at the bottom of this form. If you have any questions at any point, don’t hesitate to reach out — we’re here to help every step of the way.

We look forward to earning your trust and helping you protect what matters most in life.

Sincerely,

Kai Marder

Independent Insurance Agent/ Founder
Aurora Insurance Solutions LLC
Business Info
Personal Information

Please complete all sections of this form to allow us to provide you with the most accurate insurance quote. Not providing accurate information can result in policy premium changes once the policy goes through Underwriting. This is important as the Carriers will pull Credit and BMV Records. Thank you for your cooperation. (If a field does not apply please leave that field blank) Please refer to our privacy policy below to learn more about how we handle your private information.
Full Name
Business Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website/Social Media
Years in Business
Number of Employees (Full-time)
(Part-time or 1099)
Entity Type

Sole ProprietorLLCCorporationPartnership
Operations Section
Describe the type of electrical work you do:

Residential vs. Commercial %

	Residential	Commercial
What percent of your business is

Multiple Choice:

New ConstructionService/RepairRemodels
Do you subcontract any work?

YesNo
Do you perform work in any of the following?

High-rise buildingsIndustrial plantsHospitals/medical facilitiesGovernment or military contractsNone of the above
Insurance Needs Section
Insurance Needs

General LiabilityCommercial AutoWorkers CompensationTools & Equipment (Inland Marine)Surety/Bid/Performance BondsUmbrella Liability
Current Insurance Company
Policy Expiration Date

MonthDayYear
Date
Vehicle Section
Do you have commercial vehicles?

YesNo

If "Yes"

	Year	Make	Model	VIN	Use	Garaging Zip Code
Vehicle 1
Vehicle 2
Vehicle
Vehicle
Vehicle

Driver Info

	Name	DOB	License #	Years Driving
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5

Upload Current Insurance Docs

Cancelof
Best Time to Contact
Preferred Contact Method

CallTextEmail
Anything else you’d like to share?
Aurora Insurance Solutions LLC
Privacy Policy

Effective Date: 01/24/2025

1. Information We Collect
When you complete our intake form, we collect personal information that may include:
Full name, address, email, and phone number etc.
Driver’s license number.
Social security number.
Date of birth and marital status.
Insurance history and claims details.
Property and vehicle details.
Business information (if applicable).
We collect this information solely for the purpose of providing insurance quotes, risk assessments, and related services.

2. How We Use Your Information
We use the information you provide to:
Evaluate and quote insurance coverage.
Contact you regarding your inquiry or policy.
Comply with regulatory or underwriting requirements.
Maintain internal business records as required by law.
We do not sell, rent, or trade your personal information to third parties.

3. Sharing Your Information
We may share your data only with:
Licensed insurance carriers and underwriters for quoting and policy issuance.
Third-party service providers who help us deliver our services (e.g., CRMs, quoting tools)
Government or legal authorities if required by law or in response to legal process.
All third parties are required to protect your information in accordance with applicable privacy laws.

4. Data Security
We take reasonable administrative, technical, and physical safeguards to protect your personal information from unauthorized access, disclosure, or misuse.

5. Your Consent
By submitting this form, you:
Consent to the collection and use of your information as outlined in this policy. Agree to receive phone calls and text messages from Aurora Insurance Solutions LLC at the number you provide.
Understand that these communications may include marketing content, appointment reminders, and policy updates.
Acknowledge that message and data rates may apply, and that you may opt out at any time by replying "STOP" or contacting us directly.

6. Your Rights
You may request access to, correction of, or deletion of your personal information at any time by contacting us at:

7. Updates to This Policy
We reserve the right to update this policy at any time. Changes will be posted on our website or communicated via email when appropriate.

8. Contact Us
For questions about this privacy policy, please contact:

Kai Marder
Aurora Insurance Solutions LLC
Email: Kai.M@AuroraInsuranceSolutionsLLC.com
Call/Text: (330)-486-8133

Remote office located in Twinsburg, OH
Should be Empty:

Business/Contractor Insurance Intake Form

Business Info

Operations Section

Insurance Needs Section

Vehicle Section