OurFarmersAgent_ComProposal

Business/Commercial Insurance Proposal
Please complete the information below for a quick and easy insurance proposal!

Note: All of the information you provide is protected and encrypted.
It is only accessible by Charlie Sanchez Agency personnel.

Business Owner Information
Owner's Name*

First NameLast Name
Additional Owners Names, if any, and percentage of ownership of each
E-Mail*
Email
Phone Number*
What is the best way to contact you? (select all that apply)*

Phone CallText MessageEmailMailOther
Can we contact you based on your selection(s)?*

Yes, let's stay in touchNo thanks
Date of Birth*

MonthDayYear
Date
Driver's License Number
SSN or ITIN/Tax ID
Who referred you to us?:*

Business Information
DoingBusinessAs/ Business Name*
Company Name
Business Address*

Street Address

CityState / Province

Postal / Zip Code
Business Tax ID*
Business Start Date (mm/yyyy)*
What is your business registered as?*

IndividualLLCPartnershipCorpOther

Service Details
DETAILED Description of business practices and safety procedures. Please include as much detail as possible to avoid delays*
Please provide as much detail as possible.
Years of experience in this line of business*
Business property/contents total dollar amount $ (Do not include vehicle or trailer values in this section).*
Number of full-time employees*
Number of part-time employees*
Estimated yearly W2 payroll*
Estimated yearly 1099 payroll for employees who only perform work for your business/company (do not include subcontractor costs within this section). *
Estimated annual gross receipts*
Do you contract and pay Subcontractors to complete work for your business/company?*
Type of work performed by Subcontractors. Please provide as much detail as possible.*
Percentage of the total work performed by Subcontractors*
Total annual Subcontractor cost (non-employee compensation only)*
Are your Subcontractors insured or unInsured?*
Do you require Subcontractors to regularly provide proof of insurance to your company?*
What percentage of your work is residential?*
What percentage of your work is commercial?*
What limits of liability do you require your Subcontractors to carry?*
Do you require your Subcontractors to list you as additional insured with waiver of subrogation?*
Do you require your subcontractors to place a hold harmless clause in your favor on their policies?*
How many total projects per year does your company complete?*
Do you work on tract homes? *
How many tract homes does your company complete per year?*
Do you work on townhomes, apartments or condominiums?*
How many townhomes, apartments or condominiums do you work on per year?*

Prior Insurance Company Information
Prior Insurance Company Name*
Number of years insured
Expiration Date
Number of claims within the last 3 years (36 months)*
Detailed Description of claims/losses, if any. Who, what, when, why and where?*
Total amount insurance paid for losses

If leasing or own an office.
Upload a copy of the Lease Contract (if available)

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Own or Lease
Office/building square footage (if restaurant, how much is public square footage)
Type of alarm at this location
Is video surveillance conducted?
Total dollar amount $ spent on build-out of leased building

If delivery is part of operation.
Detailed Description of delivery business practices and safety procedures. Please include as much detail as possible:
Area(s) where business is conducted:
Drivers:
Company Vehicles:
Company Trailers:

Upload Supporting Documents.
Upload Supporting Documents

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Once all required fields are complete, Please Submit Form by clicking the link below.
Charlie Sanchez Agency, LLC & HeartStone Insurance Services, LLC
Farmers Insurance, Non-Standard Surplus Lines & Real Estate Licensed
Office (text or call): 512-251-7847
Email: Insurance@CharlieSanchez.com
Web Site: CharlieSanchez.com Fax: 512-341-9797
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