Eclipse Forms

"*" indicates required fields

Assigned Agent

Business Details

Business Name:*

Business Entity:*

FEIN / Tax-ID Number:

Contact Name*

First Last

Phone Number:*

Email:*

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:

Number of Employees:

Estimated Annual Payroll:

Estimated Annual Revenue:

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?

Personal Property Coverage

Other Changes

Vehicle Changes

Vehicle to Remove

Vehicle to Add

New Vehicle Deductibles

Add/Remove Driver Information

New Driver Information

Removed Driver Information

Document Request

Other Change Details

Business Policy Changes

Claim Information

Business Details

Additional Contractor Details

Primary Insured Information

Spouse Information

Home Information

Home Information Continued

Auto Information

Driver #2

Driver #3

Driver #4

Driver #5

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Investment Property

Motorcycle/Slingshot/ATV

Umbrella

Boat Information

Golf Cart

Recreational Vehicle

Company

Eclipse Forms

Personal Property Coverage

Other Changes

Vehicle Changes

Vehicle to Remove

Vehicle to Add

New Vehicle Deductibles

Add/Remove Driver Information

New Driver Information

Removed Driver Information

Document Request

Other Change Details

Business Policy Changes

Claim Information

Business Details

Additional Contractor Details

Primary Insured Information

Spouse Information

Home Information

Home Information Continued

Auto Information

Driver #2

Driver #3

Driver #4

Driver #5

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Investment Property

Motorcycle/Slingshot/ATV

Umbrella

Boat Information

Golf Cart

Recreational Vehicle

Company

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