Complete for business insurance quote

Mike Hackl
Hackl & Associates Insurance

Legal Business Name & Address *
All information is kept confidential
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Contact person *
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Phone number *
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Email address *
confidential & not shared
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Business type
EIN = Employer ID Number
(or Social Security if Individual)
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Insurance to quote
check all that apply
Brief description of business
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Website
If applicable
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Years in operation
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Current insurance company
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Claims in past 5 years
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Estimated annual gross revenue
confidential & needed for rating
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If property coverage selected
Limits for building &/or contents
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If work comp selected
number full time & part time employees
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Estimated annual payroll
If applicable
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If business auto selected
list year, make, model of vehicles
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Other comments
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Today's Date *
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