OurFarmersAgent_ComProposal

Application for Commercial Insurance Proposal - Please provide the following information to allow us to prepare a tailored insurance proposal for your business.

Privacy & Security Note: All information submitted is protected by encryption and will be kept strictly confidential. Access is restricted to authorized personnel at the Charlie Sanchez Insurance Agency.

Business Owner Information
Owner's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Driver's License Number
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) AND Opt IN OR Opt OUT to receive text messages and emails.*

Phone CallsText Messages *I OPT-IN TO RECEIVE TEXT MESSAGESE-mails *I OPT-IN TO RECEIVE EMAILSPostal MailI OPT-OUT OF RECEIVING TEXT MESSAGESI OPT-OUT OF RECEIVING EMAILSOther
Disclaimer: By clicking By clicking "I Opt In" and submitting this form, you consent to receive SMS messages from Charlie Sanchez Insurance Agency at (512) 251-7847 about Customer Care, Marketing or Account Notification. Message frequency may vary, and standard messaging and data rates may apply. Reply STOP to unsubscribe or HELP for assistance. For more details, see our Terms and Conditions and Privacy Policy and Website.
Terms of Service: charliesanchez.com/terms-of-service
Privacy Policy: charliesanchez.com/privacy-policy
Website: charliesanchez.com/index
Who referred you to us?:*

If any - Commercial Property Coverage
Do you own or lease a (non-residential) office/building/shop occupied and used for business?*

OwnLeaseNo Office/building/shop
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owned building replacement cost value.*
If any, please list year of complete replacement to Roof, HVAC, complete Wiring, complete Plumbing (must be full replacement to qualify)*
Office/building square footage?*
If restaurant, how much is public square footage?*
Total dollar amount $ spent on build-out of leased building*
Type of alarm at this location*
Is video surveillance conducted?*

If any - Commercial Auto or Delivery Services
Are you interested in commercial auto coverage?*

YesNo
Does your business perform any deliver operations?*

YesNo
Detailed Description of delivery business practices and safety procedures. Please include as much detail as possible:*
Area(s) where business is conducted:*
Drivers:
Business/Company Vehicles:
Company Trailers:
If any, Upload Supporting Documents e.g. copy of your current or prior policies, claims documentation, lease documents, contract requirements, additional insured docucumentation, etc...

Browse Files

Cancelof

Once all required fields are complete, Please Submit Form by clicking the link below. Thank you for giving us the opportunity to work with you!
Charlie Sanchez Insurance Agency
Office (text or call): 512-251-7847
Email: Insurance@CharlieSanchez.com
Web Site: CharlieSanchez.com Fax: 512-341-9797

1970 Rawhide Drive, Suite 210, Round Rock, TX 78681
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Application for Commercial Insurance Proposal - Please provide the following information to allow us to prepare a tailored insurance proposal for your business.