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Commercial Insurance Intake Form

Complete the form below to request a commercial insurance quote. Fields marked with * are required.

Required Information

Today's Date *

Effective Date *

Named Insured *

Business Name *

Telephone *

Email Address *

Business Address *

Business Information

Mailing Address

Line of Business Requesting

Owner Type

Type of Work

Number of Employees

Payroll

Annual Revenue

Other Partners

Years in Business

Need 3 Year Loss Runs

Current Insurance Carrier

Brief Description

Employee Info

Clerical Employees

Laborers

Salesman

General Liability

Coverage Option

Work Compensation

Officer's

Limit

Commercial Auto

How Many Vehicles?

Tools

Value of Tools

Must Schedule (if above $1,500)

Description of Tools

Commercial Property Info

Building Amount ($)

Business Personal Property ($)

# of Buildings Owned

Year Built

Square Footage

Exterior Finish

Building Updates

Roof

Heating

Plumbing

Electric

Sprinklers

Fire Alarm

Security Alarm

Signature

I understand that the insurance company or its agents may investigate my background in conjunction with this application for insurance coverage. I have answered all questions truthfully and understand that any misrepresentation may void my policy.

Name

Date

By submitting this form, you agree to be contacted by our team regarding your commercial insurance needs.