Business Name *
Address *
City *
State * State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA CANADA EUROPE MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC
Phone Number *
Years in Business
Business Structure Business Structure Sole Proprietorship Partnership LLC Corporation Non Profit Other
FEIN (Federal Employer ID Number)
Business Type Business Type Wholesaler Retailer Manufacturer Contractor Service Apartment Other
Industry
Describe your Business
Number of Full Time Employees
Number of Part Time Employees
Estimated Annual Payroll
Estimated Annual Gross Sales
Estimated Annual Sub Out
Number of Locations
Number of Owners/Partners/Officers Number of Owners/Partners/Officers 1 2 3 4 5 More than 5
Owner 1 : Name
Owner 1 : Date of Birth MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Owner 1 : Title
Owner 1 : Ownership %
Owner 2 : Name
Owner 2 : Date of Birth MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Owner 2 : Title
Owner 2 : Ownership %
Owner 3 : Name
Owner 3 : Date of Birth MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Owner 3 : Title
Owner 3 : Ownership %
Owner 4 : Name
Owner 4 : Date of Birth MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Owner 4 : Title
Owner 4 : Ownership %
Owner 5 : Name
Owner 5 : Date of Birth MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Owner 5 : Title
Owner 5 : Ownership %
Number of different Employee Class groups such as clerical, retail worker, restaurant worker, office worker, etc., Number of different Employee Class groups such as clerical, retail worker, restaurant worker, office worker, etc., 1 2 3 4 5 More than 5
List each class of worker employed along with annual payroll for each specific class group
Do you offer safety programs? Do you offer safety programs? Yes No Don't Know
Do you offer health benefits? Do you offer health benefits? Yes No Don't Know
Do you emply any minors? Do you emply any minors? Yes No Don't Know
Do you use sub-contractors? Do you use sub-contractors? Yes No Don't Know
Do you use any equipment that bends/forms/shapes? Do you use any equipment that bends/forms/shapes? Yes No Don't Know
Do you sponsor any athletic teams? Do you sponsor any athletic teams? Yes No Don't Know
Do you work up over 15 feet? Do you work up over 15 feet? Yes No Don't Know
Is the business open 24 hours? Is the business open 24 hours? Yes No Don't Know
Does the business involve any filling of propane tanks? Does the business involve any filling of propane tanks? Yes No Don't Know
Have you filed backruptcy in the past 7 years? Have you filed backruptcy in the past 7 years? Yes No Don't Know
Current Carrier Name
Current Premium Amount
MOD Factor
Current Coverage Description
Has coverage lapsed in the past 12 months? Has coverage lapsed in the past 12 months? Yes No Don't Know
New Coverage Liability Limit New Coverage Liability Limit 100/100/500 500/500/500 1000/1000/1000
Number of Claims in the past 3 years Number of Claims in the past 3 years 1 2 3 More than 3
How Did You Hear About Us? How Did You Hear About Us? Customer Referral Friend or Family Member Google Yahoo! bing Other Internet Search Sales Representative Flyer/Brochure Phone Book Radio Advertisement Television Advertisement Dave Ramsey ELP Program Billboard/Sign Email Regular Mail Door Hanger/Handbill I was referred by… Other
Additional Comments
