Business Owners Package Form

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What is your name?

Insured 1 - First Name

What is your first name?

Insured 1 - Last Name

What is your last name?

What is your phone number?

What is your email?

What is your company name?

Please provide a brief description of your business operations.

What is your role?

Owner
Manager
Other

Please provide a description of your role.

What is the primary mailing address for the company?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Company Entity Type

What is the entity type of your company?

Entity Type Other?

What is the entity type for the company?

Please enter your Federal Identification Number (FEIN)? **

Please enter your Federal Identification Number (FEIN)? *

Is there more than one owner?

Yes
No

Please list the members/owners/officers along with their respective ownership interests:

Owner/Member/Officer Full Name	Ownership Percentage (50%)

What year was the company established?

What year was the company established? (YYYY)

What is your website address? <font size="2" color="red"> (Must begin with http:// or https://) </font>

What is your website address? (Must begin with http:// or https://)

What date would you like coverage to begin?

Does the company have more than one location?

Yes
No

What is the location address for the company?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

What is the replacement cost of the building?

Please list the addresses for all company locations below:

Location Address (Street, City, State, Zip)	Usage Description	Owned or Leased?

Does the company own or lease the office location(s)?

Own
Lease
Own and Lease

What is the approximate value of the business personal property owned by the company?

What is the approximate value of the business personal property owned by the company? (Office furniture, copiers, inventory, tools, etc...)

What is the value of the improvements and betterments made to the leased location(s)?

Location Description (Main St)	Value of Improvements ($)

What is the value of the computers & media equipment owned by the company?

Any sprinkler systems at any of the locations?

Yes
No

Please list the location(s) that have sprinkler systems:

Street Address (1 Main St.)

What are the company's annual gross receipts?

Have there been any claims in the past three years?

Yes
No

Please provide a description of any claims from the past three years.

Approximate Date (MM/YY)	Claim Description	Amount Paid ($)

Does the company have any employees?

Yes
No

Please list the following information about the employees:

Number of Employees	Job Classification (ex. Clerical)	Approximate Annual Payroll ($)

Does the company own any vehicles?

Yes
No

Please provide vehicle information:

Year, Make, Model	VIN #	Leased/Financed/Owned (L/F/O)

Please provide driver information:

Driver Name	License Number	License State	Date of Birth (DD/MM/YY)

Do any of the employees use their personal autos as part of their job requirements?

Yes
No

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.

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Business Owners Package Form

Documents and Comments

Michele Bolling

RiskRevu^TM Newsletter

Contact

Business Owners Package Form

Documents and Comments

Michele Bolling

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RiskRevuTM Newsletter

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RiskRevu^TM Newsletter