Council Bluffs, IA 532 1st Ave # 101
Council Bluffs, IA 51503
(712) 322-1600
Papillion, NE 120 West Second St.
Papillion, NE 68046
(402) 331-7526
Logan, IA 207 E 7th St.
Logan, IA 51546
(712) 644-2456

Commercial Lines Intake

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Business Details

Business Name:*

Business Entity:*

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Email:*

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Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?*

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Physical Address:*

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Website Address:

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Are You A Contractor?*

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Brief Description of Operations:

Names and % of Ownership for all Officers:*

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% of Ownership

Year Business Started:

Number of Employees:

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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?

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