*StakWise – CL Renewal Form "*" indicates required fields Business Name* Full Name:* First Last Phone Number:*Email Address:* Mailing/Correspondence Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are there any significant changes in your business operation in the last 12 months? (Merger/Acquisition, New lines of business, new categories of operation, etc.)How many W-2 employees does your team currently have?* What is your projected total W-2 payroll for the upcoming 12 months?* What is your projected gross revenue for the upcoming 12 months?* What is your projected total paid to subcontractors or 1099 team members for the upcoming 12 months? (if applicable) If you have acquired any new property, added locations, or made other changes that effect your insurance needs, please detail them here.We maintain an extensive network of local professionals to help our clients with many potential needs. Please check any box below for any service you'd like a personal introduction to one of our Channel Partners in that area. Attorney (all categories) Automobile Sales Automobile Service / Repair Banker Bookkeeping Service C.P.A. or Accountant Chiropractor Commercial Lender Commercial Property Manager Commercial Real Estate Agent Computer Service / Repair Construction / Home Builder Dentist Electrician Financial Advisor Handyman / Routine Housework Hard / Private Money Lender Health or Life Insurance Agent Heating and A/C Service / Repair Landscaper Marketing agency Mortgage lender Moving Company Pest Control / Exterminator Physical Therapist Physician (All Specialties) Plumber Pool Service / Repair Residential Property Manager Residential Real Estate Agent Roofer Web Design / SEO Consulting Do your renewal policies need to be submitted to L&I? Do we need to add any additional insured's to your policy? (Bank, landlord, new contracts, etc) My business is built on referrals. What businessowners do you know that could benefit from my help? Is there anything else that we need to know now to make sure your insurance program is exactly what you need?You may upload up to 3 files to us, if necessary. Drop files here or Select files Max. file size: 100 MB, Max. files: 3. CAPTCHA
