CL Intake Form "*" indicates required fields Business DetailsCurrent Insurance StatusMy business is currently insuredThis is a new business without insuranceCurrent Insurance Policies Commercial Package (GL & Property) Commercial Auto Workers Comp / DBL - PFL Commercial Umbrella Cyber Errors & Omissions Directors & Officers Employment Practices Liability (EPLI) Other Requested Insurance Policies Commercial Package (GL & Property) Commercial Auto Workers Comp / DBL - PFL Commercial Umbrella Cyber Errors & Omissions Directors & Officers Employment Practices Liability (EPLI) Other Business Name:*Business EntityCorporationIndividual / Sole ProprietorSubchapter SLLCPartnershipJoint VentureNot For ProfitFamily TrustBusiness DBA:FEIN / Tax-ID Number:*Primary Contact Name* First Last Primary Contact Role in Business OperationsPhone Number:*Email:* Mailing Address:* Street Address Address Line 2 City ZIP Code StateNYALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYIs Physical Address Same As Mailing Address? Yes No Physical Address: Street Address Address Line 2 City 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 State ZIP Code Website Address: Requested Effective Date: MM slash DD slash YYYY Are You A Contractor? Yes No Year Business Started:*Number of Employees:*Estimated Annual Payroll:*Estimated Annual Revenue:*Please confirm that there is no cannabis related business for the named insured or possible tenants*There is no cannabis-related business related to this named insured or any tenantsThe named insured does operate in cannabis-related business or at least one tenant has a cannabis-related operationBrief Description of Operations:Additional helpful information:Additional Contractor Details% of work Subcontracted out% of Residential Work% of Commercial Work% of Remodel/Install work% of New Construction Work% of Service/Maintenance WorkDo you perform Government/Municipality Work?YesNoDo you need a policy to fulfill a certificate of insurance requirement?YesNoPlease attach any related documents for our review: Drop files here or Select files Max. file size: 39 MB. Consent* I agree to the privacy policy and provide my consent to be contacted by New Buffalo Insurance via phone call, email, text message and voicemail.https://newbuffaloinsurance.com/privacy-policy/CAPTCHA
