CL Intake

Business Details

Named Insured:

DBA (Business Name):

Business Entity:

FEIN / Tax-ID Number:

Phone Number:

Email:

Contact Person:

Tax ID:

Mailing Address:

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?

Yes

Physical Address:

Street Address City State ZIP Code

Website Address:

Effective Date:

Are You A Contractor?

Yes

Brief Description of Operations:

Names and % of Ownership for all Officers:

Full Name

Position

% of Ownership

Year Business Started:

Years’ experience:

Business Organization:

Yearly Premium:

Losses:

Number of Employees: Full Time

Number of Employees: Part Time

Estimated Annual Payroll:

Estimated Annual Revenue:

Current Insurance Carrier:

Sales/Receipts:

Property

Building value:

Year Built:

Construction:

Alarms:

Sprinklers:

Sq Footage:

Updates:

Contents value:

Property off premises:

General Liability

Insurance Limits:

Professional liability:

EPLI:

Cyber:

Employee Dishonesty:

Business Auto

Insurance limits:

Attach or ask for VIN’s of each car

Attach or ask for use of each car

Workers Compensation

Insurance Limits:

Payrolls by classification:

Owners if excluded:

Additional Contractor Details

Contractors License #

% of work Subcontracted out

% of Residential Work

% of Commercial Work

% of Remodel/Install work

% of New Construction Work

% of Service/Maintenance Work

Do you perform Government/Municipality Work?

Dec Pages / Consent

Add Dec Pages

Max. file size: 98 MB.

Request Your Proposal Here

Are you ready to save time, aggravation, and money? The team at the Oak Insurance Group is here and ready to make the process as painless as possible. We look forward to meeting you!

Start Here

Worked with Dolan to consolidate my auto and home insurance. He provided a great savings on my auto insurance and he is very professional and...

in the last week

Dan Shivaiah

The group has been super helpful with getting us new insurance policies on our new home, including auto insurance. They were able to get the...

3 months ago

Ashes DiMaria

Tessa is awesome to work with! She made the process of getting our new house insured so quick and easy and found us the best...

5 months ago

Amanda