Business & Insurance Details Form
Please complete the sections to help us understand your business and insurance needs.
SECTION 1: BUSINESS INFORMATION
Legal Business Name
*
Business Structure
*
Corporation
LLC
Partnership
Individual
Mailing Address
*
Business Website
Years in Business
Years of Experience (Owner/Operator)
SECTION 2: CONTACT INFO
Contact Name
*
Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
SECTION 3: CURRENT INSURANCE
Current Insurance Carrier
Upload Current Declarations Page (if available)
Upload a File
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of
Any claims in the last 3 years?
*
Yes
No
SECTION 4: BUSINESS OPERATIONS
Describe your business operations in detail (What do you do? What services/products?)
*
SECTION 5: FINANCIALS
Estimated Annual Revenue
Estimated Annual Payroll
SECTION 6: LIABILITY COVERAGE
Preferred Liability Limit:
$1M / $2M
$2M / $4M
Not sure (recommend for me)
SECTION 7: PROPERTY (IF APPLICABLE)
Do you have a business location?
Owned
Leased
Home-Based
None
Address of Location
Building Value (if owned)
Business Personal Property Value
SECTION 8: BUSINESS AUTOS
Do you have vehicles used for business?
Yes
No
List vehicles (Year, Make, Model, VIN if available)
Or Upload Vehicle information from a spreadsheet
Upload a File
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of
SECTION 9: EMPLOYEES / WORK COMP
Number of Employees
Describe job duties (clerical, sales, labor, etc.)
SECTION 10: DRIVER INFO (IF APPLICABLE)
List all drivers (Name, DOB, License #)
Or Upload Names, DOBs, and Driver's Licenses from a spreadsheet.
Upload a File
Drag and drop files here
Choose a file
Cancel
of
For security, you may provide driver’s license numbers by phone if preferred.
SECTION 11: OPTIONAL COVERAGES
Optional Coverages
Umbrella Insurance
Professional Liability
Cyber Insurance
SECTION 12: FINAL NOTES
Anything else I should know about your business?
SECTION 13: Personal Coverage
Would you like me to review your personal insurance (home/auto) for potential savings or better coverage?
Yes
No
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