Commercial Insurance Intake | Schomburg Insurance Agency

Coverage Needs

How did you hear about us? *

What type of coverage does your business need? *

Select all that apply. Commercial Auto requires current Declarations Pages and Loss Runs.

General LiabilitySomeone else gets hurt or their property is damaged because of your work. Property/BuildingThe building itself, if you own it. Business Personal Property - On PremisesEquipment, tools and stock kept at your location. Business Personal Property - Off PremisesTools and equipment you take to job sites or store elsewhere. Commercial AutoVehicles titled to the business. Needs current declarations pages and loss runs. Workers' CompEmployee injuries. Required in most states once you have employees. Professional LiabilityClaims that your advice or professional service caused a financial loss. Commercial UmbrellaExtra liability limits that sit on top of your general liability and auto policies. OtherSomething not listed or are you not sure? Tell us in the next question.

Describe your Other Coverage needs *

Primary Contact

Business Details

Business Name

Full Legal Business Name * DBA (if applicable)

Business Information

Entity Type Federal Employer ID Annual Revenue Annual Payroll Sub Costs Year Business Started Website URL

Description of Operations and Summary of Scope of Work *

Locations

Physical Address *

Street Address Street Address Line 2 City State Zip Code

Is your Mailing Address different from your Physical Address? *

Yes No

Mailing Address *

Street Address Street Address Line 2 City State Zip Code

Does the business have any other locations or buildings? *

Yes No

Other locations

#1

Address *

Street Address Street Address Line 2 City State Zip Code

What is at this location?

e.g. apartment building, warehouse, retail space

Owned or Leased? Year Built Square Feet Type of Construction Sprinklered? Year Roof was last Updated Building Replacement Value

Employees

Do you have employees? *

Yes No

Employee Information

# of Full Time Employees Full Time Duties/Class Full Time Annual Salary # of Part Time Employees Part Time Duties/Class Part Time Annual Salary

Office & Property

What type of office do you have? *

Home OfficeYou run the business from where you live. Commercial Office - LeasedA separate premises you rent. Commercial Office - OwnedA separate premises the business owns.

Home Office Information

Year Built Age of Roof

Commercial Office - Leased

Year Built * Square Feet * Type of Construction *

Sprinklered? *

Yes No

Year Roof was last Updated Year Plumbing was last Updated Year Heating was last Updated Year Electrical was last Updated

Commercial Office - Owned

Year Built * Square Feet * Type of Construction *

Sprinklered? *

Yes No

Year Roof was last Updated Year Plumbing was last Updated Year Heating was last Updated Year Electrical was last Updated

Building Replacement Value

Is there a Security System in place? *

Yes No

Please describe your Security System * Description and Value of Business Personal Property *

Vehicles & Drivers

Vehicles titled to the business 1 vehicle

Up to 100 vehicles.

1 Year * Make * Model * Cost New VIN

Drivers of business vehicles 1 driver

Unlisted drivers will not be covered in the event of a claim.

Up to 100 drivers.

1 First name * Last name * Date of Birth * Driver's License Number * Licensed State *

How many people drive the business vehicles?

Filled in from the drivers listed above. Change it if more people drive than you have listed.

Anything else about the drivers?

For example, accidents or violations in the last 3 years.

Attach Driver's Licenses for all Drivers

If you have them. A photo of each is fine.

Drag files here or browse (PDF or photos, up to 50 MB each)

Current Insurance

Almost Done

Explain any Special Requests or Concerns

Would you like us to look at your personal insurance (home, auto) for additional discounts? *

Yes No

Rather talk to someone?

I'd rather talk it through. Please call me.

By clicking Submit below, I am giving permission to Schomburg Insurance to contact me by phone, text or email regarding my insurance inquiry.