Commercial Intake Form

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Legal Company Name*

Type: Corp | LLC | DBA*

Incorporation or Creation Date*

FEIN #*

Primary Contact Person*

Email*

Phone

LOCATION Address*

MAILING Address*

Gross Sales (12 month estimate)*

Full Time Employees (number)*

Full Time Employees (salary)*

Part Time Employees (number)*

Part Time Employees (salary)*

Independent Contractors*

Detailed Description of Operations*

Name of Owners and Ownership %*

Lines of Coverage to be Quoted

General Liability

Property / Landlord

Professional (E&O) Liability

Workers Compensation

Management (D&O, EPL) Liability

Commercial Auto

CyberSecurity Liability

Fidelity, Surety, or Fiduciary Bond

Abuse & Molestation

Other

Desired Effective Date for Policy

Company Website

Send us copies of current policies. Also obtain loss runs for the past 5 years.

Do you have Losses or Claims in the Past 5 Years?

Additional Notes

NYS DFS Licensed P&C Broker and Life, Accident & Health Agent under #1595587

DBA Gemstone Insurance Solutions in the state of California P&C, Life, Accident & Health license number 6005098.

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