Retail Business form
Business name:
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Complete Business Address:
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Business website address
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Contact Name:
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Phone Number:
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Email:
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FEIN if you have one or SS # if you don't:
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Date Of Birth:
MM
/
DD
/
YYYY
Year Business Started:
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Year Building was built:
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Complete description of operations (the more detailed, the more accurate the quote):
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Number of years experience in this field:
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Entity type:
Building Construction Type:
Occupancy:
Years with current carrier:
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Click all that you want quotes on
Annual Payroll (W2+1099):
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Gross Annual Revenues:
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Number of employees (Full and Part time):
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Any subcontractors used?
Annual subcontractor cost:
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Do you require certificates of insurance from contractors with equal liability limits?
Square footage occupied:
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% occupied by office space:
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% occupied by warehouse space:
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Building coverage amount (If owner):
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This form was created inside of Shield Insurance Agency.