For Your Business New Business Survey All fields are required What is the name of your company?* If you use a trade name, what is it?* Who is the best person to contact for the insurance?* First Last What is the best phone number to reach them?*What is the best email to reach them?* What type of entity is the business?* Sole Proprieter Corporation LLC What is your Federal Employer Identification Number or Tax ID Number?* What is your mailing address?* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What is your local address? (If different than mailing address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What Coverage are you requesting?* Property General Liability Worker's Compensation Automobile Professional Liability Employment Practices Liability Director's and Officer's Liability Fiduciary Liability Other What date do you need to have coverage in place?* MM slash DD slash YYYY What year was the business started?* What is the website address of your company? (or description of business operations if there is not a website)* Do you currently have insurance in place for this business?* Yes No Does the company own any vehicles?* Yes No If yes, how many?What are your estimated annual sales?*What is your estimated annual payroll for employees?*How did you hear about Consolidated?* Internet Another Insurance Company Friend or Colleague Friend or Colleague Name* Would you also like a quote on any of the following?* Personal Home/Auto Health Benefits N/A Misstatements or omissions of relevant information provided can result in price variations, declinations, or rescissions of coverage. Requesting coverage does not guarantee that coverage can or will be provided. Coverage can only be bound once you have received confirmation from an authorized representative of Consolidated Insurance. 18579
