Contact Name:*

Email:*

Phone:

Year business started:*

Is this a one-time or seasonal business or event?

  Yes No

What is your business legal entity?

Corporation S Corporation Limited Liability Company Limited Liability Partnership Partnership Sole Proprietorship Limited Partnership Professional Corporation Nonprofit Corporation

What industry is your company in?

Office Retail Wholesale Manufacturing

Detailed description of  the nature of business:*     

# of Active Owners and/or Partners:*

--Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

# of Full Time Employees:*

--Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

# of Part Time Employees:*

--Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

# of Sub-Contractors:*

--Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

Approximately how many years of experience does the owner(s) of your business have in your industry? *

 Are you currently insured? 

  Yes No

If yes, what company? 

 Expiration Date:

What is your annual premium range?

$1,000 - 2,999
$3,000 - 4,999
$5,000 - 9,999

$10,000 - 19,999
$20,000 - 49,999
$50,000+

Approximate amount of professional liability coverage needed:

$1,000,000
$2,000,000
$3,000,000

$4,000,000
$5,000,000+

When do you need coverage to start?

Other information your agent should know: