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