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Home > Business > Commercial Intake Form
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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



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