Commercial Insurance Renewal Form Full Name:* First Last Business Legal Name (and DBA, if applicable): Phone Number:*Email Address:* Mailing/Correspondence Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are there any significant changes in your business operation since we last spoke? (Merger/Acquisition, New lines of business, new categories of operation, etc.)How many W-2 employees does your team currently have?* What is your projected total W-2 payroll for the upcoming 12 months?* What is your projected gross revenue for the upcoming 12 months?* What is your projected total paid to subcontractors or 1099 team members for the upcoming 12 months? (if applicable) If you have acquired any new property, added locations, or made other changes that effect your insurance needs, please detail them here.We maintain an extensive network of local professionals to help our clients with many potential needs. Please check any box below for any service you'd like a personal introduction to one of our Channel Partners in that area. Health or Life Insurance Agent Financial Advisor C.P.A. or Accountant Bookkeeping Service Attorney (all categories) Commercial Lender Commercial Real Estate Agent Commercial Property Manager Banker Hard / Private Money Lender Mortgage lender Residential Real Estate Agent Residential Property Manager Roofer Construction / Home Builder Handyman / Routine Housework Automobile Sales Automobile Service / Repair Moving Company Landscaper Electrician Plumber Heating and A/C Service / Repair Pool Service / Repair Pest Control / Exterminator Marketing agency Physician (All Specialties) Dentist Chirocractor Physical Therapist Computer Service / Repair Web Design / SEO Consulting Do your renewal policies need to be submitted to L&I? Do we need to add any additional insured's to your policy? (Bank, landlord, new contracts, etc) My business is built on referrals. What businessowners do you know that could benefit from my help? Is there anything else that we need to know now to make sure your insurance program is exactly what you need?You may upload up to 3 files to us, if necessary. Drop files here or Select files Max. file size: 98 MB, Max. files: 3.
