Internal Commercial Intake form
Agent Name:
Please Select
How did you hear about us?
Please Select
Internet search
Facebook
General Business Info:
Effective Date of Policy:
 -
Month
 -
Day
Year
Date
What would you like a quote for?
*
General Liability
Business Owners Policy
Inland Marine
Property
Commercial Auto
Work Comp
Other
Name of Business:
DBA: (if applies)
Select One:
LLC
Incorporated
Sole Proprietor
Other
Are you currently insured?
Yes
No
Name of current carrier:
Name of current broker or agency name:
Date Business Started:
 -
Month
 -
Day
Year
Date
FEIN for business:
** If no FEIN please use business owners SS#
Business Facebook link:
Carrier will do online underwriting so make sure to review this information with the client on the phone is possible.
Business website link:
Carrier will do online underwriting so make sure to review this information with the client on the phone is possible.
Number of total active owners:
List all additional owners below and percent ownership:
Primary Contact Name:
First Name
Last Name
Primary Contact Email:
example@example.com
Primary Contact Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Business Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the Insured own or lease the above business location?
Own
Lease
Is this the mailing address?
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
BOP / General Liability
Is this customer a contractor?
Yes
No
Is there sub-contracted work?
Yes
No
What is the total sub contracted payroll:
What is the total sub contracted materials cost:
Do you require COI's from all your subs?
Yes
No
Do you request to be listed as additional insured on your subs general liability and/or work comp?
Yes
No
Copy paste the current wording that is being requested:
Do you have any losses in the last three years?
Yes
No
Please provide a list of Losses below:
Last 12 Months Receipts/Sales
Total NON-Owner Payroll:
Total number of employees:
Property Insurance
Total Sq. Ft. of Building:
Construction Type:
Frame
Masonry Veneer
NON-Combustible
Other
Number of stories:
Foundation Type:
Slab
Crawlspace
Basement
Other
Year Built:
Year of improvements/upgrade:
*
Rows
Year Updated
Notes
HVAC
Electrical
Plumbing
Roof
Roof Type:
Hip
Flat
Gabel
Other
Roof Materials:
Comp Shingle
Metal
Rolled Rubber Roof
Other
Does the building have a Sprinkler System?
Yes
No
What % of the building is sprinklered?
What percentage of building does the insured occupy?
Additional Tenant Information:
Total cost of tenant buildout and betterments:
Estimated building replacement cost:
Would you like building replacement cost coverage or actual cash value:
Replacement Cost Coverage
Actual Cash Value
Desired amount of Business Personal Property coverage?
Does the building have a Alarm System?
Yes
No
Please indicate the type of alarm present:
Central Station Fire
Central Reporting Burglar
Local Fire
Local Burglar
Other
Vehicle List
Vehicle List:
Rows
Year/Make/Model
VIN
Full or Liability
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle List Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Driver List
Driver List:
Rows
Name
DOB
DL Number
Driver 1
Driver 2
Driver 3
Driver 4
Driver List Upload:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Equipment List
Type a question
Rows
Item Description
Value
Deductible
Item 1
Item 2
item 3
item 4
Equipment List Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Work Comp
Work Comp Schedule
Rows
Class Code
# of employees
Total Payroll
Class Code
Class Code
Class Code
Class Code
Use the VIAA Work Comp excel sheet in teams and upload here:
Browse Files
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Choose a file
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of
Business Narrative
Please provide a short business narrative:
Please attach any of the following here: Dec Pages, Loss Runs, Important Info:
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of
Submit
Should be Empty: