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IntegrityAR Commercial Lead Form

1StakWise - Commercial Intake - IntegrityAR

Step 1 of 3

33%

Business Details

Primary Contact Name
Names and % of Ownership for all Officers:
Full Name
Position
% of Ownership
 
Mailing Address:
Is Physical Address Same As Mailing Address?
Location Address:
MM slash DD slash YYYY
Coverage(s) Needed
Are You A Contractor?
Do you use multi-factor authentication?
Do you currently carry cyber liability?
Workers Comp Employee List
Employee Name
Position
FT/PT
Annual Salary
 
Owners Included With Workers Comp?

Additional Contractor Details

Any items valued over $5,000
List
Item Description
Value
 

Business Auto Information

Vehicle #1

Coverage Needed
Hitch
Flatbed?

Vehicle #2

Coverage Needed
Hitch
Flatbed?

Vehicle #3

Coverage Needed
Hitch
Flatbed?

Vehicle #4

Coverage Needed
Hitch
Flatbed?

Trailer #1

Is trailer enclosed?

Trailer #2

Is trailer enclosed?

Trailer #3

Is trailer enclosed?

Trailer #4

Is trailer enclosed?

Driver #1

Name
MM slash DD slash YYYY
Accidents/Violations/License Suspensions in last 3 years?

Driver #2

Name
MM slash DD slash YYYY
Accidents/Violations/License Suspensions in last 3 years?

Driver #3

Name
MM slash DD slash YYYY
Accidents/Violations/License Suspensions in last 3 years?

Driver #4

Name
MM slash DD slash YYYY
Accidents/Violations/License Suspensions in last 3 years?

Building/Property

Interest in Building:
Building originally built:
Building type:
If frame what type of siding?
Stories:
Roof Type
Sprinkler System:
Need Sign Coverage:
Is there a Premises Alarm Active?
Is there a Safe or Vault?

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