New Business Insurance Quote
Lessor's Risk Intake Form
Business Name:
*
Contact Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Are you the owner?
*
Yes
No
Do you hold 100% ownership?
Yes
No
List the Name, Title, and Ownership % of all officers (must equal 100%):
Business Type:
*
Please Select
Corportation
LLC
Partnership
Individual
Trust
Other
Description of Property:
*
Please respond to the below: - Number of Tenants: - 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 Apartment 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
Do you utilize a 3rd party property manager?
*
Yes
No
Name of Property Management Company:
Number of years in business:
*
Roof Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
Electrical Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
Plumbing Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 years old
31+ years old
Unknown
HVAC Age
Please Select
0-5 years old
6-10 years old
11-20 years old
21-30 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
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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):
Browse Files
Drag and drop files here
Choose a file
**Please upload anything that will help us quote your business. Examples include Declaration Pages to match coverages, plot maps, building photos, etc.
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I contest all the above information is true and accurate.
*
Confirm
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