Commercial Insurance Basic Form

Business Information

Please enter the name of your company. **

Please enter the name of your company. *

What is your first name? **

What is your first name? *

What is your last name? **

What is your last name? *

What is your phone number? **

What is your phone number? *

What is your fax number?

What is your email? **

What is your email? *

What is the company's website address?

What is the company's registered address? **

What is the company's registered address? *

Street Address Address Line 2 City State ZIP Code

What date was the business established?

How many years has the company been in business? **

How many years has the company been in business? *

Please select the legal structure used by the company. *

What is the company's Federal identification number?

Please provide a description of your business operations. **

Please provide a description of your business operations. *

Building Information

Is the company's primary business address the same as the company's registered address?

Yes
No

What is the company's primary business address? **

What is the company's primary business address? *

Street Address Address Line 2 City State ZIP Code

How long has the company been at this address?

Does the company own or rent/lease the business location?

Own
Rent/Lease

What year was the building built?

How many stories does the building have?

What is the total square footage of the building?

What is the value of the building?

Is there a central alarm in the building?

Yes
No

Is there a sprinkler system in the building?

Yes
No

Was the building constructed more than 20 years ago? **

Was the building constructed more than 20 years ago? *

Yes
No

Please provide information about any updates done to the building's electrical, plumbing, HVAC, and roof. **

Please provide information about any updates done to the building's electrical, plumbing, HVAC, and roof. *

Are there any other occupants of the building?

Yes
No

Please provide details about the other occupants of the building. (Ie. business name, type, etc.)

General Underwriting Information

What are the company's annual gross receipts?

What is the company's estimated total annual payroll? **

What is the company's estimated total annual payroll? *

How many Full Time employees does the company have?

How many Part Time employees does the company have?

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share how you heard about us.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

I agree *

Commercial Insurance Basic Form

Business Information

Building Information

General Underwriting Information

Documents and Comments

Brian Cook

RiskRevu^TM Newsletter

Contact

Commercial Insurance Basic Form

Business Information

Building Information

General Underwriting Information

Documents and Comments

Brian Cook

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter