Hi there! Completing this form will allow us to provide as accurate a quote as possible for general liability. The form is 39 questions, but it's easy! Thanks in advance for this opportunity! Step 1 of 2 50% Lebherz Insurance Commercial Insurance Fact Finder Name(Required) First Last Email(Required) Mobile Phone Number(Required)Do we have permission to correspond via SMS?(Required) YES NO Office Phone NumberCompany Name(Required)Federal ID Number(Required)Company Location Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte 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SaharaYemenZambiaZimbabweÅland Islands Country Company Mailing Address (If Different From Your Location Address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website Date that you formed or acquired your business:(Required) MM slash DD slash YYYY Business Structure(Required) Association Corporation Joint Venture LLC - Limited Liability Company LLP - Limited Liability Partnership Partnership - Individual Partnership - Organization Sole Proprietorship/Individual Non-Profit Registered Owners (Name, DOB, % Ownership)(Required)Number of Full Time Employees(Required)Number of Part Time Employees(Required)Total Annual Sales/Revenue(Required)Total Annual Payroll(Required)Describe Your Products and ServicesHow many years experience do you have?Sold, Discontinued, or Purchased Operations?(Required) YES NO Involved in Manufacturing, Mixing, etc.?(Required) YES NO Sell/Distribute Foreign Products?(Required) YES NO Do you require coverage for your building? ( If YES Please enter amount, if NO Please enter 0)(Required)Year of Construction or Major RenovationAge of RoofAge of PlumbingAge of ElectricalAge of HVACDo you wish to insure any business personal property (tools, office furniture, computers on premises, etc? If YES, please enter amount:(Required)Do you have any equipment that you need to insure (skid loaders, mowers, generators, medical/dental equipment, etc.) If YES, please enter items and amounts (ex: 2020 Case Skid Steer - $25,000)(Required)What is the total square foot area your business occupies?(Required)Centrally Monitored Fire/Burglar Alarm?(Required) YES NO Sprinkler System?(Required) YES NO Approximately how many customers'/employees'/patients'/clients'/tenants' information do you currently have on file?(Required)Data Types Collected(Required) Banking/Financial Information Credit/Debit cards Health/Medical Records Social Security Numbers None of the above Do you use subcontractors in the course of your business?(Required) YES NO Annual Cost of SubcontractorsIs your business currently insured?(Required) YES NO Who is your current insurer?(Required)What day does your current coverage expire?(Required) MM slash DD slash YYYY Signature
