New Business Insurance Quote
Intake Form
Name of person completing this form:
*
First Name
Last Name
Business Name:
*
Business Type:
*
Please Select
Corportation
LLC
Partnership
Individual
Trust
Other
FEIN:
Description of Business:
*
(Include your web address if you have one)
Physical Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Location same as Mailing Address?
*
Please Select
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of years in business:
*
Number of years in the industry:
*
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
When does coverage need to take effect?
*
-
Month
-
Day
Year
Do you currently have coverage in place?
*
Please Select
Yes
No
Any losses in the last 5 years?
*
Please Select
Yes
No
Reason for shopping insurance:
*
Looking for price relief
Looking for a local agent
Looking to switch agents
Looking for more options
Current insurance is getting non-renewed
New Venture
Other
If you would like to exand on the above, or provide any additional notes to our agents, please provide detail below. (Optional)
What type of coverage are you looking for?
*
Workers Compensation
General Liability
Commercial Property
Commercial Auto
Professional Liability / Errors and Omissions
Employment Practices Liability
Commercial Umbrella
Commercial Earthquake or Flood
Bond
Other
Estimated Annual Sales (or Rent, if a landlord):
Estimated Annual Payroll:
Number of Part Time Employees
Number of Full Time Employees
Does your location/property have any of the below non-standard electrical (choose all that apply):
Federal Pacific Stab-Lok Circuit Breakers
Zinsco (or Sylvania-Zinsco) Circuit Breakers
Pushmatic Circuit Breakers
Challenger Circuit Breakers
Blakeman Brothers Circuit Breakers
Knob and Tube Wiring
Aluminum Wiring
Fuses
Other
Estimated Year Updated - Roof
Estimated Year Updated - Electrical
Estimated Year Updated - Plumbing
Estimated Year Updated - HVAC
File Upload (Vehicle List and Driver List)
Browse Files
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Choose a file
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of
File Upload (Policy Documents, Loss History Reports, Rent Roll, etc.)
Browse Files
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of
I contest all the above information is true and accurate.
*
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