Business Insurance Intake Form

Contact Info

First & Last Name(Required)

First Last

Your Business Name(Required)

Phone(Required)

Email(Required)

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Is your mailing address different from your physical address listed above?(Required)

Yes

Mailing Address

Street Address Address Line 2 City State ZIP Code

Business Information

Description of Business Operations(Required)

Entity Type(Required)

Sole Prop, Corp, LLC etc.

FEIN/Tax ID #(Required)

Years in Business(Required)

Years of Industry Experience(Required)

Current Insurance Company

Current Premium

Any claims in the last 5 years? If yes, describe loss, date and amount paid. (Attach Loss Runs)(Required)

Annual Gross Sales(Required)

Annual Payroll(Required)

Number of Full-Time Employees(Required)

Number of Part-Time Employees(Required)

List Applicable Additional Insureds

Name

Address

Type (landlord, vendor, mortgagee, etc.)

Building/Property Section

Own building or rent space?(Required)

Building Limit (Replacement Cost)

Enter 0 if none

Business Property/Content Limit

Enter 0 if none

Tenant Improvements Limit

Enter 0 if none

Building Construction Type(Required)

Year Built(Required)

Building Updates(Required)

Enter the year of the most recent updates (roof, plumbing, electrical, HVAC)

Number of Stories(Required)

Total number of stories in the building

Are there fire sprinklers?(Required)

Is there a fire alarm system?(Required)

Burglar alarm system?(Required)

Building Square Feet

Occupied Square Feet(Required)

Total square feet your business occupies in the building

Sq Ft. Leased to Others

List all Inside Tenants (if you are the building owner)

Tenant Name

Square Feet

Business Operations

Include tenant names, square feet they rent and brief description of operations. Use the + button to add additional lines.

Finalize

Anything else you'd like to tell us?

How did you hear about us?

Client Referral

Online or Google Search

Preferred method of contact

Phone

Text

If available, please upload your most recent coverage documents (declaration pages)

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 98 MB.

Small Business Insurance Quote Request

Contact Info

Business Information

Building/Property Section

Finalize