Business Information
Legal Business Name
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DBA (if applicable)
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Business Address
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Phone Number
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Email Address
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FEIN
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Years in Business
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Entity Type (LLC, Corp, Sole Prop)
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Business Operations
Description of Operations
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NAICS Code (if known)
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Number of Owners / Partners
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Number of Employees (FT / PT)
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Estimated Annual Revenue ($)
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Payroll ($)
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Property & Assets
Own or Lease Location?
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Square Footage
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Building Coverage Needed?
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Business Personal Property Value ($)
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Coverage Requested
General Liability Limits
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Commercial Property
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Workers’ Compensation
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Commercial Auto
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Professional Liability / E&O
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Cyber Liability
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Umbrella / Excess Liability
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Claims History (Past 5 Years)
Describe all losses
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Current Insurance
Current Carrier(s)
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Policy Expiration Date(s)
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Current Premium(s)
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