INTERNAL - Business Discovery Form "*" indicates required fields Is this request for an existing Insured or a Prospect?* Existing Insured Prospect Line of business for quote Full Package General Liability Commercial Property Inland Marine Commercial Auto Professional Liability Workers Compensation Management Liability Other What kind of property coverage do they need?BPP OnlyBuilding OnlyBoth BPP and BuildingAddress For Property Coverage Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Requested Effective Date MM slash DD slash YYYY What is their main reason for reaching out to us now?Marketing Source (How did they hear about us?) Referred By? (if applicable) Primary Contact Name First Last Primary Contact DOB MM slash DD slash YYYY Business name Is their DBA name different from your legal entity name? DBA name is the same as legal entity DBA name is different from legal entity Their DBA (Doing Business As) name? Federal EIN Primary Business Phone*Primary Business Email* Location Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is your mailing address different than you physical address? No Yes Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Website Description of business operationsAre you contemplating any big changes or additions to your business in the next 12 months?Square feet occupied Occupancy status Owner Tenant Renovation details (roof, HVAC, plumbing, electrical)Amount of building coverageAmount of Contents / BPP coverageAny fire/security alarms? No alarms Local only Central alarm Detail all lienholders and Additional InsuredsPrevious/Current Insurance Carrier Projected Gross Revenue next 12 monthsProjected Contractor Costs next 12 monthsProjected Total Payroll next 12 monthsHow many employees / permanent 1099 contractors?Any policy declined, cancelled or non-renewed in last 3 years? No Yes Detail loss history for all LOB quoted for prior 3 yearsDoes the business own business autos or mobile equipment? No Yes Include owner(s) on work comp? No Yes General Notes
