Commercial Lines Insurance Review

Commercial Lines Insurance Policy & Risk Checkup

Please complete the form below. All fields marked with an asterisk (*) are required. CA DOI License No. #0H55923

1. Named Insured & General Business

Company Name

d/b/a (Legal Name If Different)

Entity Type

TIN Identifier Type

Federal Tax ID / EIN

Year Established

Primary Telephone

Contact Email

Company Website URL

Desired Policy Effective Date

Physical Street Address

City

State

Zip Code

Mailing Address Same As Physical?

Yes

No (Specify Separate Mailing Address)

2. Workforce & Staffing Profile

Annual Gross Sales ($)

Annual Gross Payroll ($)

Subcontracted Cost / 1099 Labor ($)

Do You Have Any Employees on Payroll?

Yes

Full Time Employees

Part Time Employees

Seasonal / Temporary Employees

3. Annual Insurance Review Questionnaire

Have You Restructured Your Company’s Ownership (e.g. Sole Proprietor To LLC/Corp) Or Added DBAs?

Yes

Has Your Business Changed Owners, Partners Or Corporate Officers?

Yes

Has The Nature Of Your Business Operations Changed?

Yes

Do You Now Also Service The Products You Manufacture?

Yes

Have You Changed Or Expanded The Types Of Products Sold And/Or Services Offered?

Yes

Have You Purchased Significant New Equipment?

Yes

Have You Added New Locations, Expanded Into New States Or Outside The US?

Yes

Have You Closed Or Moved Any Locations In The Past Year?

Yes

Detailed Description Of Business Operations

Comments, Coverage Inquiries, Or Questions

Are You a Human? Please Answer the Math Question Below:

We respect your privacy. Your information will only be used to process your insurance quotes and verify underwriting eligibility.

Corporate Office
16461 Sherman Way Suite 350
Lake Balboa, CA 91406
(818) 464-4444

Washington Office
12819 SE 38th St. Suite 430
Bellevue, WA 98006
(206) 690-5580

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