Commercial Insurance Intake Notes/Info/Referral informationBusiness Name*Business Contact* First Last Contact Email* Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business Contact Phone Number*Type of Entity* Sole Proprietor (single owner/not incorporated) Partnership (multiple owners/no incorporated/Formal Contract) S Corporation C Corporation Limited Liability Corporation (LLC) Limited Liability Partnership (LLP) Other Preferred Method of Contact* Office Phone Number Cell Phone Email What type of insurance are you interested in?* Business Owners Policy (Property AND General Liability) General Liability Business Property (Building) Business Personal Property (i.e. Furniture, Equipment, Tools, Inventory, etc) Business/Commercial Auto Insurance Workers Compensation Insurance Cyberliability Professional Liability/Errors and Omissions/Malpractice Inland Marine (ie. Large Mobile Equipment) Employment Practices Liabilty Pollution Other Let's discuss... Check all that apply - more lines = more discountsType of Business Operation*What your business does.Description of Business Operation (Longer)Business's website addressDate the business began MM slash DD slash YYYY When would you like this coverage to start? MM slash DD slash YYYY Are we replacing your current coverage? Yes No Who is/are your current carrier(s)? How long have you been with them?FEIN Number (Tax ID)Do you own the property where your business operates?* Building Owner Condo Owner Tenant Additional Policies being requestedDo you own or rent your business' space?* Own Rent Work out of the home What floor is your office located upon?Does your lease require you to insure the building/structure??* Yes No Have you paid for any improvements to your office space (walls, doors, cabinets)? Yes No Does your office have any of the following? Monitored Burglary Alarm Monitored Fire Alarm Automatic Sprinklers Doorman with limited entry What percentage of the building is covered by sprinklers?What is the value property you've purchased for the business? (Computers, desks, chairs, etc).How many square feet does your business occupy?Do you know what year your building/office was built? Yes No Year BuiltDo you know what year your building/office updated? (Plumbing, electric, roofing) Yes No Notes re: UpdatesDoes your business have any signage that is more than 500 ft from the building? Yes No If yes, what is the cost of that sign?Number of Employees*If professional office, how many attorneys/doctors/dentists do you employ?*Gross Salaries paid to employeesTotal amount of salaries paid to your employeesNumber of Owners*Will your owners be included in your workers compensation policy?* Yes No Owner's Salaries (if you want excluded/included Proposals)Gross Annual Receipts*Do your employees use their own vehicle for work?* Yes No Does your business own or lease vehicles?* Yes No Total number of cars owned/leased by businessHow will you provide us a list of your vehicles/machinery? Email a list to ken@theweikumgroup.com Give to us over the phone How many employees are listed on your current auto insurance policy?How will you provide us a list of your drivers and driver's license information? Email a list to ken@theweikumgroup.com Give to us over the phone Has the business submitted any claims or been cancelled or non-renewed in the past five years?* Yes No Note Re: Prior losses/claimsHow will you provide us a list of your prior loss runs? I will scan and email them. I'd like to connect on the phone to plan
