Dolan Test CL Intake

CL Intake – The Oak Insurance

Business Details

Named Insured:

DBA (Business Name):

Business Entity:

FEIN / Tax-ID Number:

Phone Number:

Email:

Contact Person:

Tax ID:

Mailing Address:

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?

Yes

Physical Address:

Street Address City State ZIP Code

Website Address:

Effective Date:

Are You A Contractor?

Yes

Brief Description of Operations:

Names and % of Ownership for all Officers:

Full Name

Position

% of Ownership

Year Business Started:

Years’ experience:

Business Organization:

Yearly Premium:

Losses:

Number of Employees: Full Time

Number of Employees: Part Time

Estimated Annual Payroll:

Estimated Annual Revenue:

Current Insurance Carrier:

Sales/Receipts:

Property

Building value:

Year Built:

Construction:

Alarms:

Sprinklers:

Sq Footage:

Updates:

Contents value:

Property off premises:

General Liability

Insurance Limits:

Professional liability:

EPLI:

Cyber:

Employee Dishonesty:

Business Auto

Insurance limits:

Attach or ask for VIN’s of each car

Attach or ask for use of each car

Workers Compensation

Insurance Limits:

Payrolls by classification:

Owners if excluded:

Additional Contractor Details

Contractors License #

% of work Subcontracted out

% of Residential Work

% of Commercial Work

% of Remodel/Install work

% of New Construction Work

% of Service/Maintenance Work

Do you perform Government/Municipality Work?

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