Commercial Intake

1
Company Name * This field is required.Entity then DBA if applicable
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Contact/Owner Name* This field is required.
First Name
Last Name
4
Email* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
5
Phone Number* This field is required.
Please enter a valid phone number.
6
EIN/TIN* This field is required.
7
Daily Operations of Business * This field is required.This is a normal day to day of your business please be detailed as possible.
8
Locations * This field is required.Please add in all locations your business operates in.
Huge
Large
Normal
Small
Ok
Ok
9
Rent or Own Locations* This field is required.
Rent Own
10
Business Personal Property * This field is required.Property/ things the business owns
11
Date Established* This field is required.
Date
Year
Month
Day
12
Employees and Payroll* This field is required.Include owners and partners
# of Employees
# of Owners/ Partners
Annual Payroll Costs
13
Expenses* This field is required.
14
Reason For No Coverage
15
Revenues* This field is required.
16
Signature
17
Terms and Conditions* This field is required. By submitting information through this form, you represent and warrant that all information provided is accurate and complete to the best of your knowledge, and that you are authorized to submit such information on behalf of any owner, operator, limited partner, officer, or other control person to whom the information relates. You acknowledge and agree that submission of this information grants Cuellar Capital Strategies, and any affiliated or subsidiary entities, explicit authorization to use, review, and share the submitted information with third parties for the purpose of evaluating, marketing, securing, placing, or optimizing current, future, or alternative insurance coverages or risk management solutions.You further acknowledge and agree that the information submitted may be stored and maintained in a secure database and transmitted to insurance carriers, underwriters, brokers, or other service providers as reasonably necessary in connection with the services requested. Submission of this form does not constitute a binding agreement to purchase insurance or other financial products, nor does it create an advisory, fiduciary, or agency relationship unless and until such relationship is formally established in writing.
18
Previous Coverages
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Coverages of Interest
Property
BOP
Inland Marine
Commercial Auto
GL
Workers Comp
Professional Liability/E&O
Cyber
Other
Other
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