Business Name *
Your Name *
Your Position * Select Shareholder/Owner Senior Management Research Manager HR Manager Support Team Member
Your Phone *
Your Email *
Best Time to Contact You * Select Morning Afternoon Evening Weekend
Preferred Contact Method * Select Phone Email Text
Business Address *
Describe What Your Business Does *
Web Address
Entity Type * Select S Corp C Corp LLC Non-Profit Sole-Proprietorship Partnership
Years in Business * Select 3 or Less 4 or More New Venture
Years of Industry Experience * Select 10+ More than 3 Less than 3
Reason for Considering Change * Select Cost, Coverage, & Service Strictly Price Past Claim Activity New Business
Other States or Foreign Operations * Select No Yes Contemplated in the Next Year
Personal Insurance Review * Select Yes No, Thank You
Group Health Insurance Review * Select Yes No, Thank You
Life Insurance Review * Select Yes No, Thank You
Secondary Contact's Name *
Secondary Contact's Email *
Secondary Contact's Phone *
Current Carrier
Proposed Effective Date *
Need by Date *
Number of Full Time Employees *
Number of Part Time Employees *
Payroll Projections *
Subcontractors Cost *
Gross Sales/Receipts Projections *
General Liability Limit Desired Select $1,000,000/$2,000,000 $2,000,000/$4,000,000
Hired & Non Owned Auto Liability Desired Select Yes No
Fire Legal Damage to Property Limit Desired Select $100,000 $300,000 $500,000 $1,000,000
Professional Liability E&O Limit Desired Select 1/1 1/2 2/4 N/A
Cyber Liability Limit Desired Select $25,000 $50,000 $100,000 $250,000 $500,000 $1,000,000
Options for Umbrella Limit Desired Select $1,000,000/$1,000,000 $2,000,000/$2,000,000
Is There an Immediate Need for Certificates of Insurance or Additional Needs Select No Yes
Current Carrier Name
Proposed Effective Date *
Need by Date *
Approximate Age of Building * Select 0 to 25 Years 26+ Years
Age of Electric/Plumbing/Roof/HVAC * Select 0 to 25 Years 26+ Years
Years at this Location * Select 1 to 5 Years 6-10 Years 11-15 Years 16-20 Years 20+ Years
Business Personal Property (Business Equipment & Inventory) Limit Desired
Mobile Equipment Coverage Limit Desired
Tenant Improvements and Betterments Limit Desired
Building Insurance Limit Desired
Loss of Income or Rental Income Limit Desired
Crime Insurance Limit Desired
Earthquake and Flood Coverage Limit Desired
Property in Transit Coverage Limit Desired
Other
Current Carrier
Desired Effective Date *
Need By Date *
Include or Exclude Owners for Coverage Select Include Exclude
Employers Liability Limits Desired Select $100,000/$100,000/$100,000 $100,000/$500,000/$100,000 $1,000,000/$1,000,000/$1,000,000 $2,000,000/$2,000,000/$2,000,000
Employee Classification
Number of Employees
Projected Payroll
Employee Classification
Number of Employees
Projected Payroll
Employee Classification
Number of Employees
Projected Payroll
# of Owners
Current Carrier
Proposed Effective Date *
Need by Date *
Number of Vehicles
Number of Drivers
Combined Single Limit Desired Select $1,000,000 $2,000,000
Uninsured/Underinsured Motorist Limit Desired Select $1,000,000 $2,000,000
Medical Payments Coverage Limit Desired Select $1,000 $5,000 $10,000 None
Have There Been Any Losses in The Past 5 Years? Select Yes No
If Yes, Please Explain
