Commercial Lines Intake

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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?

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Commercial Lines Intake

Business Details

Additional Contractor Details

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