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

Smith Davis 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

No

Physical Address:

Street Address City State ZIP Code

Website Address:

Effective Date:

Are You A Contractor?

Yes

No

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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