TEMPLATE – Super CL Intake Step 1 of 3 33% Business DetailsAssigned AdvisorBrooke HenleyMatthew LeeNiki HenleyHow did you hear about us?Realtor ReferralMortgage ReferralCustomer ReferralGoogleFacebookWebsiteCurrent CustomerInternal Referral (Office Use Only)Internal Referral SourcesAAA InsuranceAAA Prior CustCarrier DirectCross-SellCurrent CustomerCustomer ReferCustomer ReferralDavis LawExtra Mile WebsiteFacebookFamilyFRMS- Gordon, TGold StarGold StarGoogle/Search EngineIAOAIns Agnt-UnknownInstagramLinkedInMtg-1st UnitedMtg-ArvestMtg-Flat BrnchMtg-GatewayMtg-Nw Am FundMtg-Pro MtgMtg-UFFCMtg-UFFC-TahlMtg-unknownMtg-ZfgNetwking eventNetworkingOLT-B. ParkerPersonal FrndProfessional ReferralRealtorRemarketRewriteRltr- OtherRltr-Chin&CohnRltr-Cnt21Rltr-Coldw BnkRltr-EXPRltr-Klr WlmsSF-BillingsSF-Bryan SmithSF-S. LaneSF-T.BledsoeWalk-inWinbackWho Referred you?Business Name:Business Website:Business EntityIndividual/Sole ProprietorLLCINCPartnershipOtherFEIN / Tax-ID Number or Social Security NumberPrimary Contact Name First Last Phone Number:Email: Names and % of Ownership for all Officers:Full NamePosition% of Ownership Add RemoveMailing Address: Street Address 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 Is Physical Address Same As Mailing Address? Yes No Location Address: Street Address 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 Years of ExperienceRequested Effective Date: MM slash DD slash YYYY Year Business Started:Coverage(s) Needed Business Auto Building/Property Cyber Liability General Liability Workers Comp Are You A Contractor? Yes No Do you use multi-factor authentication? Yes No Do you currently carry cyber liability? Yes No Current Cyber CarrierNumber of Full-Time Employees:Number of Part-Time Employees:Workers Comp Employee ListEmployee NamePositionFT/PTAnnual Salary Add RemoveOwners Included With Workers Comp? Yes No Estimated Annual Payroll:Estimated Gross Annual Revenue/Sales:Amount of Liability CoverageAmount of Business Contents/Property CoveragePlease provide a short description of business operations:Additional Contractor DetailsContractors License #% of work Subcontracted out% of Residential Work% of Commercial Work% of Remodel/Install work% of New Construction Work% of Service/Maintenance WorkDo you perform Government/Municipality Work?YesNoTools/Equipment coverage needed?YesNoAny items valued over $5,000ListItem DescriptionValue Add Remove Business Auto InformationHow many vehicles are owned by the business?1234How many trailers are owned by the business?01234How many drivers work for the business?1234Current Carrier:Current Payment Plan:Vehicle #1Vehicle #1 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage Value of VehicleDeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #2Vehicle #2 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage Value of VehicleDeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #3Vehicle #3 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage Value of VehicleDeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Vehicle #4Vehicle #4 VIN# of jobs per dayCoverage Needed Liability Only Full Coverage Value of VehicleDeductibleHitch No Yes in Bed/Bumper Flatbed? Yes No Gross Weight# of Axels2345Trailer #1Trailer ValueLengthIs trailer enclosed? Yes No Serial #Trailer #2Trailer ValueLengthIs trailer enclosed? Yes No Serial #Trailer #3Trailer ValueLengthIs trailer enclosed? Yes No Serial #Trailer #4Trailer ValueLengthIs trailer enclosed? Yes No Serial #Driver #1Name First Last DL#SSNDate of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #2Name First Last DL#SSNDate of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #3Name First Last DL#SSNDate of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Driver #4Name First Last DL#SSNDate of Birth MM slash DD slash YYYY Accidents/Violations/License Suspensions in last 3 years? Yes No Building/PropertyCurrent CarrierInterest in Building: Owner Tenant % of building occupied:% leased to others:Building originally built: Slab Crawl Space Building type: Frame Masonry If frame what type of siding? Wood Vinyl Stories: 1 2 3 Total Square Feet:Roof Age:Roof Type Shingles Wood Shingles Metal Clay Tiles Age of Wiring:Plumbing:Heating:Sprinkler System: Yes No Need Sign Coverage: Yes No Amount of CoverageIs there a Premises Alarm Active? Yes No Is there a Safe or Vault? Yes No How often does applicant make a deposit of cash?Value of Building:Value of Personal Contents:Coverage requested:
