General Information:
 
1.  *First Name:  
2.  *Last Name:  
3.  *Phone:  
4.  *Email:  
5.  Address:  
6.  Address:  
7.  City:  
8.  *State:  
9.  *Zip Code:  
9.  County:  
The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.
1) Description of the business:
2) What type of entity is your company?
3) Please indicate the state in which your business is located:
4) What is the date of incorporation?
MM/YY
5) Please indicate your total number of full-time employees:
(If Sole Proprietor enter 1)
6) Please indicate your total number of part-time employees:
(If none please enter 0)
7) Please indicate your total annual revenue:
8) Do you currently have business insurance? Yes No
9) If you are currently insured, please select your current insurance carrier:
10) If your provider is not listed above, please provide the company name here:
11) How many years have you had coverage with this company?
12) How many years have you had continuous coverage (With no lapse)?
13) If you do not have coverage please indicate when you would like a policy to go into effect:
14) What is the business address?
15) City:
16) State:
17) Zip code:
18) Do you own or lease this location? Own Lease
19) What hours are you open for? TO
20) Is your business open on weekends or do you or any employees work in the office over the weekend? Yes No
21) Indicate the liability amount you need:
22) How much of a deductible do you want your policy to include:
23) Please check off any additional coverage's/riders you want your new policy to include:
Fire Insurance
Miscellaneous Professional Liability
Employee Dishonesty
Product Liability Insurance
 		 Business Interruption Insurance
Hazard Insurance
Excess Insurance Policy
Manufacturers and Contractors Liability (M&C)
 
24) In the past five years, have you been a party to any lawsuits or filed any claims? Yes No
25) If you answered yes, were those claims:
Please complete the questionnaire, and we'll begin our search for the most suitable disability insurance policy for your business.
26) Best Time To Contact:
27) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

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