Business Insurance Info sheet
Business Owner Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Full Business Name (Entity + DBA if applicable)
Entity Type
Sole Prop
LLC
Corp
Partnership
Other
TAX ID/FEIN/SSN
Year Biz Established
Description of Operations
# of Locations
Own or Rent?
Annual Gross Sales
Business Personal Property (Inventory, furniture, or any property the business owns)
Give us a dollar amount you would need on a blank check to replace all of your business personal property
FT / PT Employees
Estimated Payroll
Type of Building
Do you have a central station fire/burglar alarm?
Sq Ft
Previous Insurer and Policy Number
Current policy premium? (monthly/yearly/quarterly) - The more we know, the more competitive we can be!
Renewal / X-Date
-
Month
-
Day
Year
Date
Any Losses or Claims in the past 3 years?
Submit
Should be Empty: