Powell - Forms - StakWise

"*" indicates required fields

Business Details

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:

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?

FORMS

Business Details

Additional Contractor Details

Primary Insured Information

Spouse Information

Home/Condo Information

Home Information Continued

Auto Information

Driver #2

Driver #3

Driver #4

Driver #5

Auto Coverage Info

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Vehicle #5

Investment Property

Motorcycle/Slingshot/ATV

Umbrella

Boat Information

Golf Cart

Recreational Vehicle

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