Business/Commercial Insurance Intake Form
Starkey and Associates Insurance Solutions
Legal Business Name
Name
DBA (if applicable)
Business entity type (LLC, Corp, etc.)
FEIN (Federal Tax ID)
Years in Business
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Owner's Information
Owner's Name
First Name
Last Name
Phone Number
Owner's Phone Number
Email
Owner's Email Address
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website / Social Media Links
Business Phone Number
Please enter a valid phone number.
Business Email Address
example@example.com
Preferred Contact Method
Phone
Text
Email
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Business Operations
Detailed Description of Operations
(Please describe the type of work your business performs.)
NAICS Code (if known)
(optional)
Annual Gross Revenue
(Estimate if exact amount is unknown.)
Annual Payroll (if known)
(Optional)
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Employees
Part-time
Add number of Employees
Full-time
Add number of Employees
Do you use subcontractors?
Yes
No
Are certificates required from subcontractors?
Yes
No
Hours of Operation
Territory of Operations
Please Select
Local
Regional
National
International
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Insurance Coverage Needs
Desired Effective Date
-
Month
-
Day
Year
(When would you like your coverage to begin?)
Types of Coverage Needed
General Liability
Commercial Property
Business Owner's Policy (BOP)
Commercial Auto
Workers' Compensation
Professional Liability (E&O)
Cyber Liability
Umbrella / Excess Liability
Inland Marine
Employment Practices Liability (EPLI)
Are there any contracts requiring specific insurance?
(Please describe or list any contract requirements.)
Desired Limits / Deductibles (if known)
(Optional – share any preferences or requirements for coverage limits and deductibles.)
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Property Details (If insuring building or contents)
Property Address
(Full address of the insured property)
Year Built
(e.g., 1995)
Construction Type
Square Footage
Number of Stories
Building Updates (Check all that apply)
Roof
Electrival
Plumbing
HVAC
None / Not Sure
Building Owner or Tenant?
Owner
Tenant
Both
Alarm System or Sprinkler System?
Yes
No
Are there tenants in the building?
Yes
No
Business Personal Property Value
Inventory/Stock Value
Equipment Description and Value
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Commercial Auto (if applicable)
Vehicle Details
Enter Year, Make, Model, and VIN for each vehicle (one per line).
Use of Each Vehicle
(e.g., delivery, sales, client visits, equipment transport)
Garaging Address
(Where each vehicle is stored overnight)
Driver Information
Provide Name, Date of Birth, and Driver's License Number for each driver.
Years of Driving Experience
(Per driver if multiple)
Annual Mileage
(Estimated yearly mileage per vehicle)
Any Personal Use?
Yes
No
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Workers' Compensation
Employee Job Duties
Describe each employee’s role or responsibilities.
Payroll by Job Type (if known)
(e.g., Clerical – $50,000; Sales – $40,000)
Work at Heights or Out of State?
Yes
No
Subcontractor Certificates Collected?
Yes
No
Prior Claims
Browse Files
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Choose a file
(Attach loss runs or describe prior claims)
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Prior Insurance History
Current or Past Insurance Carriers
Coverage Types & Limits
Policy Term Dates
-
Month
-
Day
Year
Date
Any Coverage Lapses?
Yes
No
Claims in the Past 5 Years?
Browse Files
Drag and drop files here
Choose a file
(Attach loss runs if available)
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Additional Notes
Any Lawsuits, Bankruptcies, or Criminal History?
Yes
No
If yes, please describe.
Future Expansion or New Services Planned?
Upload Photos
Browse Files
Drag and drop files here
Choose a file
(Building, Equipment, Vehicles)
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Schedule an appointment for your free home insurance quote consultation. Choose a date that works for you!
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