Business Insurance

Business Insurance

New Business Client General Request Form
IMPORTANT

Your privacy and data security are our top priority. All information submitted through this form is securely stored and protected using advanced RSA‑2048 encryption technology. This ensures that your personal and policy details remain confidential, safeguarded against unauthorized access, and handled in compliance with insurance industry data protection standards.
Let's get started getting to know more about your business
Contact Name*

Title / PositionFirst NameLast NameSuffix
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email*
example@example.com
Are You the Risk Management Decision Maker?*

YesNoTeam Decision
List All Risk Management Decision Makers with Title / Position*

Grade Your Current Insurance Experience*

Rows	A	B	C	D	F	N/A
Premium Cost
Agent's Overall Communication
Agent's Responsiveness
Agent's Risk-Management Guidance
Agent's Annual Policy Review
Insurance Carrier's Claims Handling

Agent / Carrier Satisfaction*

We're satisfied with our agent, but dissatisfied with our insurance carriersWe're dissatisfied with our agent, but satisfied with our insurance carriersWe're dissatisfied with our agent, and dissatisfied with our insurance carriers
Since you're satisfied with your current insurance carriers, would you be willing to sign a Broker of Record form to reassign your current policies to our agency?*

YesNoMaybe
How Would You Describe Your Team's View of Insurance and Risk Management*

Strategic Risk Partner – We view insurance as essential to business success, we value risk management, we consider professional guidance, and we actively seek advice to optimize coverage and adequately protect our business's risk exposures.Informed & Proactive – We understand the importance of insurance, we have generally positive experiences and are open to recommendations from our agent, though not deeply engaged in risk management strategies.Practical & Compliant – We see insurance as necessary for protection and compliance, but mostly focus on meeting requirements and reducing costs, rather than optimizing coverage.Skeptical & Cost-Focused – We question the value of insurance because we have had mixed or negative experiences with the insurance industry in the past, and primarily shop for the lowest cost with minimal engagement.Resistant & Distrustful – We hold an unfavorable view of the insurance industry, and we generally view insurance as a “necessary evil” that feels like a scam, and we prefer minimal or bare-bones coverage at the absolute lowest cost.
Current Insurance Policies (check all that apply)*

General LiabilityCommercial PropertyCommercial AutoCommercial UmbrellaManagement LiabilityProfessional LiabilityWorkers' CompensationInland MarineCyber LiabilityEnvironmental LiabilityEquipment BreakdownGroup HealthSurety BondsOtherNone
Other Insurance Coverage (list all)
Explain the Reason This Business is Uninsured*
Business Legal Name*
Doing Business As (if applicable)
Business Entity Type*
Business Start Date*

MonthDayYear
Date
Is This Business a Parent or Subsidiary Company?*

NoParentSubsidiary
List All Subsidiary Entities Owned By This Business*
List All Parent Entities That Own This Business*
Business Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Fax Number (if applicable)
Please enter a valid fax number.Format: (000) 000-0000.
Business Email*
example@example.com
Business Website URL (if applicable)
www.domain.com
Business Main Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Identification Number Type*

FEINITINSSN
FEIN / ITIN*
SSN*
Company Revenue and Payroll
Total Annual Revenue*
Total Annual Payroll*
Full Time Employees (current)*
Part Time Employees (current)*
Contractors
Does this business hire sub-contractor businesses to perform services?*

YesNo
# of Sub-Contractors*
Does this business hire temporary non-employee contract workers?*

YesNo
# of Contract Workers*
Company Vehicles and Drivers
# of Company-Owned Vehicles*
# of Hired / Non-Owned Vehicles*
# of Approved Employee Drivers*
# of Approved Contracted Drivers*
Types of Vehicles Used in the Company Fleet (check all that apply)*

Passenger Car / Minivan / SUVClass 1-2 Light-Duty TruckClass 3-4 Medium-Duty TruckClass 5-6 Medium-Duty TruckClass 7 Heavy-Duty TruckClass 8 Heavy-Duty TruckOtherN/A
Describe the Business Operations / Services*
Any Business Insurance Claims or Losses in the Last 5 years?*

YesNo
List All Claims / Losses in the Last 5 Years (date, type, amount, and description)*
Any Additional Information You Can Provide
Current Policy Declarations Upload

Upload all current policy declarations pages here to expedite your application process
Cancelof
I hereby affirm that all information provided on this form is true, accurate, and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts may affect the accuracy of insurance quotes or the validity of coverage. By checking the box below, I acknowledge that I have reviewed my responses and agree to this statement. I also understand that completion of this form constitutes a request for insurance and does not guarantee the issuance of a policy or provide any insurance coverage or binding authority. Coverage will become effective only upon approval by the insurance carrier and the issuance of a policy or binder through an authorized representative.*

I agree
I consent to being contacted by phone or email by a Sebastian Williamson Insurance Solutions agent when additional information is needed to complete my insurance application. For my protection, the agency will identify itself using the following six-digit verification PIN code that I provide below.*

I agree
PIN CODE*
Referral Code (if available)
Please verify that you are human*
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Business Insurance

Let's get started getting to know more about your business