New Business Insurance Quote
Lessor's Risk Intake Form
Business Name:
*
Contact Name/Owner Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Business Type:
*
Please Select
Corportation
LLC
Partnership
Individual
Trust
Other
FEIN:
Description of Property:
*
Please respond to the below: - Number of Units: - Describe your Tenants: (Office, Restaurant, Salon, etc.) - Number of Stories: - Roof Type: - Parking Lot Size or Number of Spaces:
(Include your web address if you have one)
Physical Location of Building:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the square footage of this location?
Are there multiple buildings?
*
Please Select
Yes
No
List buildings and their square footage:
Physical Location same as Mailing Address?
*
Please Select
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years of Ownership:
*
Roof Age
*
Please Select
0-5 years old
5-15 years old
15-30 years old
31+ years old
Unknown
Electrical Age
*
Please Select
0-5 years old
5-15 years old
15-30 years old
31+ years old
Unknown
Plumbing Age
*
Please Select
0-5 years old
5-15 years old
15-30 years old
31+ years old
Unknown
HVAC Age
*
Please Select
0-5 years old
5-15 years old
15-30 years old
31+ years old
Unknown
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.
*
True
False
Estimated Annual Rents
*
When does coverage need to take effect?
*
-
Month
-
Day
Year
Do you currently have coverage in place?
*
Please Select
Yes
No
Current Insurance Carrier:
Fire Protection (check any that apply):
*
Fully sprinklered interior
Central station fire alarms
Local fire alarms
Aluminum wiring on premises
None of the above apply
Any losses in the last 5 years?
*
Please Select
Yes
No
Explain any losses:
Upload 5 Years of Loss History (if available):
Browse Files
Drag and drop files here
Choose a file
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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
Additional File Upload (Optional). If you have your current declarations page available, this will help us match or improve your current coverage limits.
Browse Files
Drag and drop files here
Choose a file
Examples: Declaration pages, plot maps, building photos, etc.
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I contest all the above information is true and accurate.
*
Confirm
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