Commercial Insurance Intake Form

Commercial Insurance Intake Form

Help us get you the best coverage. Please fill out the information below and an agent will respond within 24 working hours.
Basic Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the business address different from your mailing address?
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Information
Are there multiple owners?
Who are the active owners of the business? (please list all first & last names)
Name of Business
Entity Type
Describe your business and what all it does. Please be detailed so that we can explain to underwriters and get you accurate supplemental applications to expedite the quote turn around.
When was the business established?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many years of experience do you have in this field of work?
Hours of Operation
What is your estimated annual gross revenue?
Do you use sub contractors (independent business owners)?
What is your annual cost to sub contractors?
Do you have employees?
How many W2 employees?
Annual Payroll for W2 Employees:
How many 1099 employees?
Annual Payroll for 1099 Employees:
How many square feet is your commercial building? If no building, enter 0
Do you own your commercial building?
How many businesses occupy the building?
Year Built:
Year of Plumbing:
Year of Electrical:
Roof Type:
metal, shingles, etc.
Roof Age:
Building Construction Type:
masonry, metal, etc.
Does your business serve alcohol?
Do you have video surveillance at this location?
Do you have commercial vehicles?
Does your business have property that needs to be insured? (equipment, supplies, products, etc.)
Please list all property you wish to be insured. Include serial number, year, make, model, and value.
Current Insurance Information
Do you have currently have commercial insurance?
Current Insurance Company
Current Policy Limit
What is your EIN? This can be found on your IRS CP 575 letter, previous years tax return, or business bank paperwork.
Will you need a commercial auto policy?
Permissions & Additional Information
Do we have permission to text the provided number(s)?
Do we have permission to quote your commercial insurance?
Preferred Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about us?
Which team member?
Texas Broker Fee Disclosure

Bartose Insurance Agency may charge a non-refundable broker fee for services such as quoting, marketing, placement, and servicing of your insurance policy. This fee is separate from the insurance premium, fully earned when charged, and will not be refunded even if coverage is not purchased, canceled, or later changed.

Texas Required Notice:

Broker fees are not required by law and are negotiable.
Broker fees are not set or regulated by the State of Texas.
This broker fee is in addition to any commissions the agency may receive from the insurance carrier.
You may request additional information about how this fee is determined.
By submitting this form, you acknowledge that you understand and agree to the non-refundable broker fee as disclosed.
Signature
Should be Empty:

Commercial Insurance Intake Form

Basic Information

Business Information

Current Insurance Information

Permissions & Additional Information