Nick Patides Commercial Insurance Request
What is your name?
*
First Name
Last Name
Job Title
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What type of business entity is it?
*
Please Select
Corporation
Individual
Joint Venture
LLC
Not for Profit Org
Partnership
Subchapter "S" Corporation
Trust
Other
What is the business entity's name?
*
FEIN
*
Website address
*
If none, please put N/A
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What types of coverage are you looking for?
*
Business Owners Policy
Workers Compensation
General Liability
Property
Business Personal Property
Errors and Omissions
Commercial Auto
Other
Requested Effective Date
*
-
Month
-
Day
Year
Date
Is coverage required for a loan closing?
*
Yes
No
Loan Closing Date
*
-
Month
-
Day
Year
Date
Property Limits Requested?
*
Business Personal Property Limits Requested?
*
Business Income/Loss of Rents Requested?
*
Betterment & Improvements Limit
*
Contents Limit
*
Is the property address for the business different than the mailing address?
*
Yes
No
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you own the property, are newly purchasing, or plan to occupy as a tenant?
*
Own
Purchasing
Tenant
What square footage will you be occupying?
*
Is there a Mortgagee or any entity requesting to be listed as an additional insured and/or loss payee?
*
Yes
No
Name of Additional Insured?
*
Loan Number
Address of Additional Insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the nature of the business?
*
Please Select
Apartments
Contractor
Manufacturing
Restaurant
Service
Beekeeping
Condominiums
Institutional
Office
Retail
Wholesale
Lessor's Risk
Date Business Started
*
-
Month
-
Day
Year
Date
Please describe the operations
*
Have you had any claims in the past 5 years?
*
Yes
No
Loss History
*
Rows
Date of Claim
Description of Claim
Amount Paid
Claim 1
Claim 2
Claim 3
Estimated revenue for this year
*
Number of employees not including yourself
*
Estimated payroll for this year
*
Submit
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