Commercial Insurance Request
Business Name
Contact Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years in business
*
Please Select
1
2
4
5+
Business Type/Industry
*
(Example: Restaurant, Contractor, Retail, Office, etc.)
Description of Operations (very important)
Number of Employees
*
(Example: Restaurant, Contractor, Retail, Office, etc.)
Annual Revenue (Estimate)
*
(Example: Restaurant, Contractor, Retail, Office, etc.)
Business Structure:
Sole Proprietor
LLC
Corporation
Partnership
What type of coverage are looking for?
General Liability
Commercial Property
Business Owner's Policy (BOP)
Workers Compensation
Commercial Auto
Professional Liability (E&O)
Cyber Liability
Umbrella / Excess Liability
Other
Do you own or rent your space?
Own
Lease
Building Square Footage
Year Built
Construction Type
Number of Vehicles
*
Types of Vehicles
Pickup
Van
Box Truck
Other
Do you current have insurance?
Please Select
Yes
No
Current Insurance Company
Policy Expiration Date
Current Premium
Reason for Shopping
Lower Premium
Better Coverage
Business Growth / Changes
Policy Non-renewal
New Business
Any claims in the past 5 years?
Please Select
Yes
No
How did you hear about us?
Note any additional details. (If applicable, desired coverage limits, claim details, business operations, etc.)
Upload your business documents, current insurance, etc. Or email documents to info@cmlegacyinsurance.com
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your business documents, current insurance, etc. Or email documents to info@cmlegacyinsurance.com
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload your business documents, current insurance, etc. Or email documents to info@cmlegacyinsurance.com
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
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