Do you need Business Insurance?

Business Name

Number of Members or Managers

Telephone number and type (If you can accept text messages, let us know if that is okay to contact you that way)

How many years have you been in business? If you are a new business, type new.

Size of office in square feetIf you work out of your home, how much of your home is used for the business?

Description of Operations. What does your business provide to your customers?

Do you own or rent your location building?(required)

Own

Rent

Estimated Gross annual sales(required)

Up to $25,000

$25,001 – $100,000

$100,000- $250,000

Over $250,000. We will contact you to get this information.

Do you have employees?(required)

Yes

Total Payroll Amount per month paid

What limit of liability insurance do you need?

$1,000,000 per occurrence / $2,000,000 aggregate

$2,000,000 per occurrence / $4,000,000 aggregate

First Name

Last Name

Street address of Business

Address (Suite, Apartment #)

City, State, Zip

Do you have a different mailing address?(required)

Yes

Mailing street address

Mailing City, State, Zip

Web Address even if it is not published yet

CLAIMS HISTORYHave you had any liability insurance claims in the past 5 years?(required)

Yes

Have there been any recent incidents that could result in a claim?(required)

Yes

Are you in compliance with all County, State, Federal Food and Safety Regulations?Choose several options(required)

Yes

What is your Employer Identification Number (EIN)?

What is the Date that you need this by?

Please list the products sold or services rendered?

By filling out the preceding form, you agree to be contacted by an agent with Get Help With Insurance, Inc. There are a lot of sites out there that would sell your info to other agents. We will not do that. Bonnie Grant will work with you to get the insurance that you need. Call our number if you need immediate attention. The number is (702) 541-0882

Get Help With Insurance, Inc.

Phone Number

Contact Address

Email Address

Phone Number

Contact Address

Email Address

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