Commercial Account Information Date: MM slash DD slash YYYY Prepared By:*Alonso, FrancescaBalco, CraigDugan, LeeAnnHilliard, SherrinLamb, KaylaLevi, DouglasMella, TonyPirko, PhyllisYoung, AmyDate of Birth MM slash DD slash YYYY How did you hear about us?When is the last time you heard from your agent?Business Name:Business Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work/Home Phone Number:Email:* Preferred Method of Contact Phone Email Text Contact Person:Referred by:Wouldn’t it feel good to know you are getting the proper insurance protection & the best possible price?Purchase/Renewal Date? MM slash DD slash YYYY Other than price, which we know is the most important, what ELSE is important to you when buying insurance?If Incorporated, what is your Tax ID Number?What is the square footage of the building?What was last year's Gross Revenue (Or expected for New Venture)?What was last year’s payroll (Or expected for New Venture)?When is the last time you reviewed your payroll service to make sure you are getting competitive rates?When is the last time you have reviewed your 401k, 403b, group benefits to make sure you are getting competitive rates?Does your current agency provide you with an Executive Summary? Yes No Own or lease? Own Lease Please provide details of business (What duties exactly the business performs):Years In Business or Experience in Business:Building Value (Or Betterments for Tenants):Year Building Built:Construction type:Number of stories:Subcontract Payroll:Year of updates (Only if building is older than 1997)Wiring:Plumbing:Heating:Roof:Roof TypePrior Coverage (if so w/who?)AlarmAny Section 8 housing, or Pool? Yes No Any claims in the last 5 years? Yes No If yes, please provide details:Coverage Extensions- Recommend Hired & Non-owned, Ord & Law Coverage & BIIf you have a current Declaration Page showing your current coverage’s, that would be extremely useful so we will be able to quote your needs more accurately.Respectfully yours,Doug LeviNotes:We want to let you know how we get paid. We get paid two ways; one is a commission that comes from the company directly, not from your pocket, and the other is by referrals from our clients. So if we do a good job for you, we hope that you would consider to refer us to your friends, family & co-workers.Communication Policy I agreeI consent to receiving SMS and/or Email communications relating to this request. By submitting this form, you consent to receive SMS messages and/or emails from our company. To unsubscribe, follow the instructions provided in our communications. Msg & data rates may apply for SMS. Your information is secure and will not be sold to third parties.NameThis field is for validation purposes and should be left unchanged.
