• Retail Insurance Intake

    Complete this commercial retail insurance intake form with the business, policy history, location, and notes details requested.

  • Prospect and Business Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Business Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred Contact Method*

  • Policy Relationships and History

  • Does the applicant currently have existing insurance policies?*
  • Which types of existing policies are in place?
  • Is workers' compensation coverage currently in force?
  • Are there any other businesses owned or related to the applicant?
  • Other businesses owned or related
  • Are there any additional interests to note?
  • Is blanket coverage requested?
  • If blanket coverage is requested, what categories should be included?
  • Prior carrier 1 effective date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Prior carrier 1 expiration date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Prior carrier 2 effective date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Prior carrier 2 expiration date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Has any policy been canceled, non-renewed, or declined in the past 5 years?
  • Which action(s) occurred?
  • Cancellation or non-renewal effective date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Was the cancellation due to nonpayment?
  • Was the cancellation due to claims activity?
  • Any lapses in coverage in the past 5 years?
  • Are any related parties to be listed on the policy?

  • Location and Property Details

  • Location / Property Records - Only if Building Coverage is Desired
  • Year Built
     - -
    2 digit month, 2 digit day, 4 digit year
  • Condo Coverage Option
  • Sprinklers
  • Vacancy Status
  • Alarm System
  • Parking Lot
  • Video Surveillance
  • Location-Specific Risk Features
  • Does the location have a basement?
  • Is the location fully occupied?
  • Any prior losses at this location?
  • Any roof updates?
  • Any plumbing updates?
  • Any electrical updates?
  • Any HVAC updates?
  • Fire extinguishers present?
  • Fire alarm monitored?
  • Security alarm monitored?
  • 24/7 building access?
  • Is there a loading dock?
  • Is there a warehouse area?
  • Any hazardous materials stored?
  • Are repairs or construction ongoing?
  • Is the building sprinklered?
  • Is the property fenced?
  • Is there exterior lighting?
  • Any flood protection measures?
  • Is the location leased?
  • Does the lease require insurance?
  • Is there signage coverage needed?
  • Any tenant improvements in place?
  • Any shared walls or common areas?
  • Is this a standalone building?

  • Other Coverages

  • Other coverage types carried*
  • General Liability in force?
  • Umbrella coverage in force?
  • EPLI coverage in force?
  • Pollution coverage in force?
  • Business life coverage in force?
  • Personal lines coverage in force?
  • Personal lines X-date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Additional insured status for other coverages?
  • Waiver of subrogation required?
  • Primary and noncontributory required?

  • Notes

  • Note Category
  • Requires Follow-Up
  • Should be Empty: