Commercial Checklist

Commercial Checklist
Which Agent have you been working with?
Legal Business Name *
FEIN # *
Primary Point of Contact *

First Name Last Name
Phone Number *

Area Code Phone Number
Primary E-mail
Secondary Point of Contact

First Name Last Name
Phone Number

Area Code Phone Number
Secondary E-mail
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Business Details
Duties Performed by Business (Please list all) *
Years in Business *
Years with Current Insurance Provider *
Gross Annual Sales *
Physical Address (If Different than Above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Owner 1

First Name Last Name
Percentage of Ownership (1)
Owner 2

First Name Last Name
Percentage of Ownership (2)
Additional Owner Information
Web Address
Do you have Resources? *

Employees Only Contractors Only Employee and Contractors None
Annual Employee Payroll *
Annual Contractor Costs *
Driver List
Driver 1

First Name Last Name
DOB 1

Month Day Year
Driver 1 License #
Driver 2

First Name Last Name
DOB 2

Month Day Year
Driver 2 License #
Driver 3

First Name Last Name
DOB 3

Month Day Year
Driver 3 License #
Driver 4

First Name Last Name
DOB 4

Month Day Year
Driver 4 License #
If more than four drivers, please enter into a .doc or .xls and attach below
Attach Declaration Pages from Current Carrier
Attach Loss Runs
Attach Other Relevant Documents (As Requested)
Enter the message as it's shown *
Signature *

Clear
Should be Empty:

Business Details