Clone of Business Insurance - New Quote Intake Form (Restaurants)

New Business Insurance Quote

Apartment Intake Form
Business Name:
Contact Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Are you the owner?
Do you hold 100% ownership?
List the Name, Title, and Ownership % of all officers (must equal 100%):
Business Type:
Apartment Description:
Please respond to the below:

- Number of Units:
- Number of Stories: 
- Are pets allowed? Y/N
- Are BBQ's allowd on balconies: Y/N
- List other features (such as pool/jacuzzi, recreational area, laundry room, etc.):(Include your web address if you have one)
Are there gas wall heaters?
What type of fireplaces (if any)?
Physical Location of Apartment Building:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the square footage of this location?
Are there multiple buildings?
List buildings and their square footage:
Physical Location same as Mailing Address?
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you utilize a 3rd party property manager?
Name of Property Management Company:
Number of years in business:
Roof Age
Electrical Age
Plumbing Age
HVAC Age
I do not have any of the following at my location: Knob and Tube Wiring, Aluminum Wiring, Federal Pacific/Stab Lok Panels, Zinsco Panels, or Challenger Panels.
Estimated Annual Rents
Choose if you have any of the below exposures:
Provide % of each exposure checked above (must equal 100%):
Are BBQ's allowed on balconies?
Please choose from the below regarding pets:
When does coverage need to take effect?

MonthDayYear
Do you currently have coverage in place?
Current Insurance Carrier:
Any Swimming Pools?
Please confirm:
Fully fenced: Y/N
Self latching gates: Y/N
Diving Board: Y/N
Slide: Y/N
Depth markings clearly visible: Y/N
Rescue equipment available: Y/N
Provide any other detail needed:
Any Playgrounds?
Describe the playground equipment.
Fire Protection (check any that apply):
Any losses in the last 5 years?
Explain any losses:
Upload 5 Years of Loss History (if available):

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Reason for shopping insurance:

Other
Additional File Upload (Optional):

**Please upload anything that will help us quote your business. Examples include Declaration Pages to match coverages, plot maps, building photos, etc.
Cancelof
I contest all the above information is true and accurate.
Should be Empty:

New Business Insurance Quote