Your Name
Your Email
Your Phone#
Business phone number.
Annual Revenue
Helps determine coverage limits and risk level.
# Of Employees
Determines Workers Compensation and Employment Practices Liability.
Industry/Sector
Tailors specific coverages and risks.
Current Insurance
If yes, please specify the types of coverage you currently have.
Claims in the Last 5 Years?
If yes, please briefly describe the nature and outcome of each claim.
Own or Lease Primary Business Location?
If leased, does your lease require specific insurance coverages or limits?
Are Vehicles Used for Business Operations?
If yes, how many vehicles do you use? What is the approximate annual mileage for these vehicles? Do employees drive personal vehicles for business purposes?
Does the Business Handle Sensitive Client Data?
If yes, how do you store and manage this data (ie: cloud-based, internal servers, etc)?
Do you Manufacture, Distribute, and/or Sell Products?
If yes, briefly describe the types of products and their intended uses.
Regularly Work/Operate at Locations Away From Your Primary Business Address?
Any Other Applicable Information?
