Commercial Insurance Intake
Karen Ray Insurance Agency
Commercial Insurance Intake Form
Owner's Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Basic Business Information
Which best describes your business?
*
Retail (I sell products to people)
Restaurant (I prepare and serve food or drinks)
Service (I provide a service to customrers)
Contractor (I build, repair, or service things)
Office (I run a business in an office setting)
Landlord (I rent or lease properties to others)
How is your business structured?
*
Sole Proprietor
LLC
Corporation
Partnership
Association
S-Corporation
LLP (Limited Liability Partnership)
Legal Business Name
*
If you have a DBA, what is that?
What does your business do?
*
Business Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your company's website:
*
What is your expected revenue for the next 12 months?
*
What year was your business established?
*
What date do you need this policy to start?
*
As a small business owner, what is the one thing that keeps you up at night?
Do you currently have business insurance
*
Yes
No
Current policy expiration date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How much are you paying with your current carrier?
*
Property Details
Does your business own or rent its location?
*
Own
Rent
Tell us about your building:
What best describes the building construction?
*
Frame (made mostly of wood)
Joisted Masonry (brick or concrete walls with wood framing inside)
Non-Combustible (construction of metal or steel)
Masonry Non-Combustible (brick or concrete walls with a non-combustible roof)
I don't know
Is the building fully sprinklered?
*
Yes
No
Approximately how many square feet is the entire building where you do business?
What square footage does your business occupy?
*
How much have you invested in upgrades to your rented space?
*
How much (in dollar amount) do you carry in business personal property (equipment, desks, tools, computers, printers, inventory, etc)?
*
Employee Details
How many owners, LLC members and executive officers do you have?
*
Do you have any employees working for your business?
*
Yes
No
Not counting owners, how many employees do you have? (1099 included)
*
FEIN
*
Employee Payroll: Please enter the annual estimated payroll for ALL of your non-officer employees in the category that most accurately reflects their job duties:
Include 1099 employees
Part-Time
*
What are the duties of the part-time employees?
*
Full-Time
*
What are the duties of the full-time employees?
*
Almost done! Just a few more questions.
The owners of the business are onsite and involved in daily operation.
*
True
False
The management team has little turnover.
*
True
False
There are regular safety meetings helps daily/weekly/monthly.
*
True
False
There are formal hiring practices in place.
*
True
False
There is a formal employee training program in place.
*
True
False
The following equipment is on a scheduled routine maintenance contract:
Is video surveillance present? If so, how many cameras and how is it monitored?
*
What company do you currently have commercial insurance through?
Submit
Should be Empty: