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Business Information
Please enter the name of your company. *
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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? *
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What is your phone number? *
What is your fax number?
What is your fax number?
What is your email? *
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What is your email? *
What is the company's website address?
What is the company's website address?
What is the company's registered address? *
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What is the company's registered address? *
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What date was the business established?
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. *
Please select the legal structure used by the company. *
Sole Proprietor
Partnership / LLP
Corporation
LLC
PC
What is the company's Federal identification number? *
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What is the company's Federal identification number? *
Please provide a description of your business operations. *
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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?
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
How long has the company been at this address?
How long has the company been at this address?
Does the company own or rent/lease the business location?
Does the company own or rent/lease the business location?
Own
Rent/Lease
What year was the building built?
What year was the building built?
How many stories does the building have?
How many stories does the building have?
What is the total square footage of the building?
What is the total square footage of the building?
What is the square footage of the space occupied by the company?
What is the square footage of the space occupied by the company?
Does the building have multiple tenants?
Does the building have multiple tenants?
Yes
No
What is the square footage occupied by the other tenants?
What is the square footage occupied by the other tenants?
What is the value of the building?
What is the value of the building?
Is there a central alarm in the building?
Is there a central alarm in the building?
Yes
No
Is there a sprinkler system in the building?
Is there a sprinkler system in the building?
Yes
No
Was the building constructed more than 20 years ago? *
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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?
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.)
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 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 Full Time employees does the company have?
How many Part Time employees does the company have?
How many Part Time employees does the company have?
Have there been any claims in the past 5 years?
Have there been any claims in the past 5 years?
Yes
No
Please provide the date of loss, a description of the loss, the claim's status (open/closed), and claim amount.
Please provide the date of loss, a description of the loss, the claim's status (open/closed), and claim amount.
Date of Loss
Description
Status (Open/Closed)
Claim Amount
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)
Drop files here or
Select files
Accepted file types: pdf, jpg, Max. file size: 128 MB, Max. files: 5.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Referred by...
Google search
Agency's website
Email newsletter
Current customer
Facebook
Instagram
Twitter
Other
Please share who referred you to us.
Please share who referred you to us.
Please share what you typed into Google.
Please share what you typed into Google.
Please share how you heard about us.
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 *
Cecilia Rivera
860-868-7361
http://ericsoninsurance.com/
Cecilia_Rivera@ajg.com
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