Theresa General Liability Intake Form – Blanchard Insurance

Business Name(Required)

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Contact Name(Required)

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Phone Number(Required)

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Email Address(Required)

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Business Property Address(Required)

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

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Is the Business Mailing Address Different Than the Property Address?(Required)

Yes

No

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Business Mailing Address(Required)

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

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Website

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Legal Entity Type(Required)

LLC, Corporation, Sole Proprietor

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Years in Business(Required)

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FEIN #(Required)

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Description of Operations(Required)

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Estimated Annual Gross Revenue(Required)

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Estimated Annual Payroll(Required)

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Number of Employees(Required)

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Any Subcontractors used?(Required)

Yes

No

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If yes, are certificates of insurance required?(Required)

Yes

No

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Prior Liability claims in the last 5 years?(Required)

Yes

No

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If yes, please describe:(Required)

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Would you also like a quote for Commercial Property Insurance?(Required)

Yes

No

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Does the business own the building?(Required)

Yes

No

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Year Built(Required)

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Construction Type(Required)

Frame, Masonry, etc.

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Square Feet(Required)

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Number of Stories(Required)

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Is the building sprinklered?(Required)

Yes

No

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Is there a central alarm?(Required)

Yes

No

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Any prior property losses in the past 5 years?(Required)

Yes

No

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If yes, please describe:(Required)

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Estimated Building Replacement Value(Required)

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Business Personal Property Value(Required)

Equipment, inventory, etc.

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Additional Notes or Special Coverage Requests

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