Lotfey CL Intake Form

Commercial Lines Intake Form

Business Name:

Business Entity:

FEIN / Tax-ID Number:

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:

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?