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618 Insurance Agency

(618) 433-8880
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Commercial Client Intake Form

Business Name*
Business Contact*
First Last
Contact Email*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Contact Phone Number*
Preferred Method of Contact*
- Office Phone Number
- Cell Phone
- Email
Type of Entity*
- Sole Proprietor (single owner/not incorporated)
- Partnership (multiple owners/no incorporated/Formal Contract)
- S Corporation
- C Corporation
- Limited Liability Corporation (LLC)
- Limited Liability Partnership (LLP)
- Other
Type of Business Operation*
What your business does.
FEIN Number (Tax ID)
Date the business began
Date Format: MM slash DD slash YYYY
What type of insurance are you interested in?*
- General Liability
- Business Property (Building)
- Business Personal Property (i.e. Furniture, Equipment, Tools, Inventory, etc)
- Business/Commercial Auto Insurance
- Workers Insurance
- Inland Marine (ie. Large Mobile Equipment)
- Professional Liability/Errors and Omissions/Malpractice
- Cyberliability
- Employment Practices
- Pollution
- Other
- Let's discuss...
Check all that apply - more lines = more discounts
Do you currently have business insurance?
Name of your current carrier:
How many years have you been with your current carrier?
Do you own or rent your business' space?*
- Own
- Rent
- Work out of the home
How many square feet does your business occupy?
Gross Annual Receipts*
Number of Employees*
Number of Owners*
Will your owners be included in your workers compensation policy?*
- Yes
- No
Do your employees use their own vehicle for work?*
- Yes
- No
Does your business own or lease vehicles?*
- Yes
- No
Total number of cars owned/leased by business
How will you provide us a list of your vehicles/machinery?
- Email a list to ryan@618ins.com
- Give to us over the phone
How many employees are listed on your current insurance policy?
How will you provide us a list of your drivers and driver's license information?
- Email a list to ryan@618ins.com
- Give to us over the phone
How will you provide us a list of your prior loss runs?
- Do you need our help to get them?
- I will scan and email them.
- I'd like to connect on the phone to plan
- I'll fax them to Ryan @ 618-433-8880

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618 Insurance Agency

3021 Godfrey Rd
PO Box 5233
Godfrey, IL 62035

(618) 433-8880

ryan@618ins.com

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