Named Insured / Business Owner(Required) First Last Please list the business owner's name here. Additional Owner or Contact Support First Last Business Name (exactly as it appears on the business license)(Required) Please let us know the business name, exactly as it appears on the Business License. Business Type(Required)LLCCorporationIndividualPartnershipNon-ProfitFEIN UBI# Mailing Address(Required) Street Address City State / Province / Region ZIP / Postal Code Year Business Started Years of Experience Please share how much experience you have in doing this work. Current Insurance Current Insurance Expiration Date Any claims in the last 5 years? Brief Description of Business Operations(Required)Is the Business Seasonal?NoYesEstimated Gross Sales How much do you anticipate making this year in your business? Employees How many employees do you have, will you be hiring this year. Please indicate if they are full time or part time. Building / PropertyOwnRentN/APlease indicate if you own or rent your building or working space. Building DetailsIf you own or rent a building or office, please share the address and any requirements. Do you want coverage for your equipment, tools or business property?YesNoN/ADescribe Equipment, Tools or Business PropertyPlease describe any equipment, tools or business property and the estimated value. Additional Coverages Needed Employment Practices Liability Directors & Officers Cyber Crime Scheduled Auto Hired Auto Liability Non-Owned Auto Liability Commercial Umbrella Please check each additional coverage you're interested in and add notes in the comments. Notes / Requests / Questions for usReferral Source Please let us know how you were referred to our team. Your Name(Required) Please share who is filling out this form? Preferred Method of Confirmation *Include Email Address or Phone# If you prefer the quote is sent to you via email or text, please provide that information. If you prefer a phone call, please share the phone number and best time of day for a phone call.Agent's Email Address(Required) Please include the Agent's Email Address that this form will be submitted to: *Alex@northtowninsurance.com *Aaron@northtowninsurance.com *Joey@northtowninsurance.com
