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Legal Entity Information Form
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What is your first name? *
*
What is your first name? *
What is your last name? *
*
What is your last name? *
This field is hidden when viewing the form
What is your name?
What is your name?
What is your email address? *
*
What is your email address? *
What is the mailing address for the legal entity?
What is the mailing address for the legal entity?
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 is the name of the legal entity? *
*
What is the name of the legal entity? *
What is the type of legal entity?
What is the type of legal entity?
Limited Liability Company (LLC)
Trust
Limited Liability Partnership (LLP)
Family Limited Partnership (FLP)
Other
Please enter the type of legal entity:
Please enter the type of legal entity:
Is there a tax ID or FEIN? *
*
Is there a tax ID or FEIN? *
Yes
No
What is the occupancy type of this residence?
What is the occupancy type of this residence?
Primary Home
Secondary Home
Seasonal Home
Investment Property
Rental Property
Who are the occupants of this property? *
Who are the occupants of this property? *
Is this property rented at any time during the year? *
*
Is this property rented at any time during the year? *
Yes
No
How often is it rented? *
*
How often is it rented? *
Who is the property rented to? *
*
Who is the property rented to? *
Please enter the tax ID or FEIN.
*
Please enter the tax ID or FEIN.
Is the property vacant during the year? *
*
Is the property vacant during the year? *
Yes
No
How long is the property is vacant? *
*
How long is the property is vacant? *
Is there a permanent resident or caretaker living on the premises? *
*
Is there a permanent resident or caretaker living on the premises? *
Yes
No
What is the name of the permanent caretaker or resident who lives 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 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. *
*
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you. *
Principal/Beneficial Owner Name/Trustee(s)
Relationship to you
What is the purpose or intent of the entity?
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...
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?
Yes
No
Please provide details about the income generation and business conducted by this entity.
Please provide details about the income generation and business conducted by this entity.
Does the entity generate income in any other ways?
Does the entity generate income in any other ways?
Yes
No
Please provide a description of the other ways this entity generates income.
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?
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Yes
No
Please list the other assets this entity owns:
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Does the entity have any employees?
Does the entity have any employees?
Yes
No
Please list the name and occupation for each of the employees:
Please list the name and occupation for each of the employees:
Name
Occupation
Please describe how the employees are paid.
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Does the entity maintain any other insurance policies?
Does the entity maintain any other insurance policies?
Yes
No
Please provide the insurance company name(s), coverage type and coverage limits for the other 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...)
Please use this field to upload any relevant documents. (ie. Current policy declarations pages, etc...)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 10.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
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 *
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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