Nick Patides Commercial Insurance Request

Nick Patides Commercial Insurance Request
What is your name?*

First NameLast Name
Job Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What type of business entity is it?*
What is the business entity's name?*
FEIN*
Website address*
If none, please put N/A
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What types of coverage are you looking for?*

Business Owners PolicyWorkers CompensationGeneral LiabilityPropertyBusiness Personal PropertyErrors and OmissionsCommercial AutoOther
Requested Effective Date*

MonthDayYear
Date
Is coverage required for a loan closing?*

YesNo
Loan Closing Date*

MonthDayYear
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?*

YesNo
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own the property, are newly purchasing, or plan to occupy as a tenant?*

OwnPurchasingTenant
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?*

YesNo
Name of Additional Insured?*
Loan Number
Address of Additional Insured*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the nature of the business?*
Date Business Started*

MonthDayYear
Date
Please describe the operations*
Have you had any claims in the past 5 years?*

YesNo

Estimated revenue for this year*
Number of employees not including yourself*
Estimated payroll for this year*
Should be Empty:

Rows	Date of Claim	Description of Claim	Amount Paid
Claim 1
Claim 2
Claim 3