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Commercial Intake Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Information

Company Name *

Entity Type

DBA Name

FEIN *

Nature of Business

Number of Owners

Year Business Established

How many years of experience do you have?

Company Owner

First Name *

Last Name *

Street Address

City, State. ZIP Code

E-Mail Address *

Policy Information

Coverage Amount *

Gross Annual Sales

Products Comp Ops

Rented Premises

Medical Pay / PIP

Number of Officers/Partners

Officer Payroll

Number of Employees FT/PT

Annual Employee Payroll

Annual Cost of Subcontractors

Discrimination/Sexual Harassment Coverage

Employee Benefits Liability

Claims/Property Losses in Past 5 Years (Please Explain)

Current Insurance Provider

Years with current carrier

Current Policy End Date

Any Additional Insured's or Waiver of Subrogation required?

Property Information

Building 1

Premises Address

Building Description

Building Limit

Coverage Type

Business Personal Property Limit

Deductible

Construction Type

Year Built

Square Footage *

Roof Type

Roof Install Date

Electrical Update

Plumbing Year Update

HVAC Update

If Lessor Risk, Name of Business occupying

Property Questions (if applicable)

Glass Coverage

If Yes, Linear Feet of Glass

Exterior Sign or Awning

If Yes, Value

Money & Securities

If Yes, Amount on Premises and Off Premises

Employee Theft

Back Up of Sewer and Drains

If yes, Value of basement contents

Earthquake Coverage

Flood Coverage

Equipment Coverage

Claims/Property Losses in Past 5 Years (Please Explain)

Current Company, how many years

Expiration Date

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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(316) 686-6666 1819 S. Rock Road Suite 101 | Wichita, KS 67207

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Location

1819 S. Rock Road, Suite 101
Wichita, KS 67207

P: (316) 686-6666
F: 316-425-0025