Business and Agricultural Insurance Intake Form
Please fill this form out to the best of your ability so we can design an insurance program tailored to your specific needs. You can reach out to us at 970-353-3608 or sean.browning@american-national.com with questions!
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
example@example.com
Are You Currently Insured
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
What Insurance Products are you in need of?
*
Business
Agriculture/Farm
Commercial Auto
Worker's Compensation
Employee Benefits
Life Insurance
Retirement Planning
Business Insurance
Do you want a business proposal? We cannot provide one without the following information.
*
Yes
No
What is the name of your business?
Co-Owners? List names and DOB
What is the nature of your business?
FEIN if applicable?
Number of Employees
Yearly Payroll
Annual Sales
Years in Business
Have you ever had an insurance policy non-renew, cancel, or be declined?
Please explain if so
Agricultural / Farm Insurance
Nature of Farming Operations
Select all you need to insure
Residence
Outbuildings
Livestock / Horses
Hay / Grain / Fodder
Machinery
Business Liability
Other
END
How did you hear about our agency?
*
Any other details to assist us in creating your insurance program?
By submitting this form and/or providing the above information, you agree to receive text message and email communications from our office.
Submit Form
Should be Empty: