Patrick Chua Agency, Inc
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Business Name
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Primary Contact Person
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First Name
Last Name
Best Phone Number to Contact
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
Head Officer
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Title
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List Owners and Percentage of Ownership
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Business Ownership Structure (LLC, Scorp, Corp, etc.)
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Business Address and Mailing Address (if different)
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Business Phone Number
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Business Email
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Business Website (enter NA if no website)
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FEIN
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Year Business Established (YYYY format)
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How many years of experience do you have in the industry?
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# of FT Employees
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# of PT Employees
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Annual Revenue
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Annual Payroll (excluding owners/officers)
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Owner Annual Payroll
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Do you hire subcontractors or 1099 workers? If yes, what % of sales is through subcontractors
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In layman's term, describe what the business does.
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Is the business home based, leasing a space, or owns a commercial space?
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How much in business personal property do you need? This would be any furnishings, equipment, appliances or electronics, tools, etc that you use for your business?
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What type of insurance do you already currently have for the business? Specify the carrier for each insurance.
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What type of insurance do you think you need for the business?
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When does coverage need to start?
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