What is your first name? *
What is your last name? *
What is your name?
What is your email address? *
What is the mailing address for the legal entity?
What is the name of the legal entity? *
What is the type of legal entity?
Please enter the type of legal entity:
Is there a tax ID or FEIN? *
What is the occupancy type of this residence?
Who are the occupants of this property? *
Is this property rented at any time during the year? *
How often is it rented? *
Who is the property rented to? *
Please enter the tax ID or FEIN.
Is the property vacant during the year? *
How long is the property is vacant? *
Is there a permanent resident or caretaker living on the premises? *
What is the name of the permanent caretaker or resident who lives on the premises?
Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you. *
What is the purpose or intent of the entity?
Does the entity generate income or conduct business with regards to the appreciation of owned property, private residential rental income, management of wealth for the benefit of the principal owners or incidental business?
Please provide details about the income generation and business conducted by this entity.
Does the entity generate income in any other ways?
Please provide a description of the other ways this entity generates income.
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Does the entity have any employees?
Please list the name and occupation for each of the employees:
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Does the entity maintain any other insurance policies?
Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Documents and Comments
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
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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.