Business Name * Business Address * Phone * (###) ### #### Email * Occupation * Years in business * Legal Entity * Choose one LLC Partnership Sole Proprietorship S Corporation C Corporation Annual Revenue * $100,000- $500,000 $500,000-$1,000,000 $1,000,000-$5,000,000 $5,000,000- $10,000,000 Over $10,000,000 Under $100,000 # of owners/partners * # of full-time employees # of part-time employees # of sub-contractors Description of operations Annual payroll $ Property and casualty insurance General liability Commercial auto Commercial property Professional liability (E&O) Directors and officers liability Business owners package policy (BOP) Workers compensation Commercial crime Employee benefits Group health insurance Group life insurance Group disability insurance 401K / retirement plans Supplemental plans / AFLAC Key man life insurance Key man disability insurance Deferred compensation Comments/ Special Instructions Thank you!
