Name Insured
*
First Name
Last Name
Effective Date
*
-
Month
-
Day
Year
Date Picker Icon
Name of Business/Organization
*
Address
*
Phone
*
Fax
*
Email
*
Entity Type
*
Individual
Partnership
Life Insurance
Corp
LLC
Would you explain in a detailed form about the operation and services?
Fed Tax ID#
*
Years in Business
*
Years in Experience
*
Annual Gross Revenue
*
Annual Payroll $ # of Employees( Part-Time/Full-Time)
*
Business Property (Contents, equipment & tools):
Do you own the building?
Yes
No
Square Foot
Year Built
Construction Type
Does your job offer you family health coverage?
Yes
No
Sprinkler
Yes
No
Central Alarm
Yes
No
Prior Insurance Company
Any Prior Losses ?
Yes
No
Worker Comp: In force ?
Yes
No
Health Insurance Offered ?
Yes
No
Do you offer delivery ?
Yes
No
Business Auto Coverage needed ?
Yes
No
Alcohol Sales (Amount and percentage of total Sales)
By checking this box, I agree to receive SMS messages about Customer Care from Let’s Insure at the phone number provided above. This may include your (Appointment reminders, Follow-up messages, Confirmation of Submission, Transactional Updates) The SMS frequency may vary. Data rates may apply. Text HELP to 877-851-7867 for assistance. Reply STOP to opt out of receiving SMS messages. Please review our
Privacy Policy
and
Terms and Conditions
.
Submit
Should be Empty: