Andy Commercial Intake Form – Blanchard Insurance

Business Name(Required)

General Description of Work(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What year did the business start?(Required)

How many owners?(Required)

Owner's name(s)(Required)

Years of experience in trade?(Required)

How much work in each category: commercial, residential, industrial(Required)

What type of work do employees perform?(Required)

Number of employees(Required)

Expected payroll over the next 12 months(Required)

Expected subcontractor payables over 12 months?(Required)

Expected total sales in 12 months(Required)

Any recent claims or violations regarding insurance?(Required)

Yes

If you answered yes to the above question, please provide details of the claim

When would you like coverage to start?

Phone number(Required)

Email Address(Required)