Commercial Lines Form

Commercial Lines Form

Step 1 of 8

Business Information
Business Legal Name
DBA

Years in Business
BUSINESS FEIN
BUSINESS TYPE
Estimated annual wages for all employees
Estimated annual gross sales of the company
Amount spent on contractors

Property Information
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Location Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are they a home based business?
Do they own or rent their location?

Owner Information
Name*
First Last
Email
Phone*
Date of Birth
Date Format: MM slash DD slash YYYY
Percentage of Ownership
Date Format: MM slash DD slash YYYY

Owner #2 Information
Owner #2 Name
First Last
Owner #2 Date of birth
Date Format: MM slash DD slash YYYY
Owner #2 Percentage of Ownership

Owner #3 Information
Owner #3 Name
First Last
Owner #3 Date of birth
Date Format: MM slash DD slash YYYY
Owner #3 Percentage of Ownership

Do Owner's want to "Include" or "Exclude" from coverage?
If "included", what are the job duties & estimated annual wages for each officer

Please provide a detailed description of the business operations
Thank you
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