In-take Form For Insurance Quote

In-take Form For Insurance Quote

Please complete all applicable fields

Client Details
Account ID
Legal Entity Name*
Legal Entity Type*
Is Your Entity Registration Active With The State*

YesNoPending
Does This Entity Operate Under a DBA?*

YesNo
What is the name of the DBA and its specific business function?
Account Name
FEIN
PEO/ASO/Non Payroll
Website Address
Mailing Address
Add Location Addresses for Each Operating State*
Owner Name

First NameLast Name
Owner Email
example@example.com
Owner Phone
Please enter a valid phone number.
Contact Name (if different than owner)

First NameLast Name
Contact Email (if different than owner)
example@example.com
Contact Phone (if different than owner)
Please enter a valid phone number.
Years In Business
How Many Years of Experience In Your Current Industry?
Number of Full Time EE's
Number of Part Time EE's
Estimated Annual $ Amount for F/T Payroll
Estimated Annual $ Amount For P/T payroll
Previous Carrier
Do You Have Loss Runs? (hover mouse for info)
To provide you with the most accurate quote we will need a copy of your loss runs.

There is a place at the end of this form to upload documents. If you have your loss runs you can upload them there.

If you do not have them, you can email them to wc@teamworksgroup.com after you finish this form.
Dec Pages
Estimated Sales
How Many Jobs Per Year
Tract Homes
Description of Operations*
Sales & Payroll Detail*
i.e. - Gross Revenue - $150K Payroll Clerical 8810 - $40K Payroll YMCA Fitness Boxing 9063 - $42K Also break this information out by Full Time and Part Time by code as necessary
List 3rd Parties Needing Evidence of Insurance (Name, address, preferred contact info; name, email)
List 3rd Parties also needing to be listed on the policy as insureds (Name, address, preferred contact info; name, email)
The below sections represent the different policies we can offer.

You do not need to fill out each section, just those you are interested in us quoting for you.

Simply click the arrow to the right of the section to drop it down and expose the fields.

GL
Residential %
Commercial %
Does Applicant Hire Subcontractors
Sub Costs

Work Comp
Included/Excluded
Owner Info
Do you know your class codes?
Add States and Class Codes Per State (please enter the state, class code, and annual payroll amount per class code. i.e. UT - 8810 - $10,000) Put each class code on a new line.
Please add list of company positions (INCLUDING OWNER IF COMING ON MASTER POLICY) and simple description of each positions duties. Example: Position = Receptionist, Position Duties = Clerical*

Property
Is Property Coverage Needed
List Property Info Below (click Add Row to add more properties)

Auto
Is Business Auto Coverage Needed
Vehicle List
Driver List
Do you need Hired/Non-Owned/or Any auto coverage?

HiredNon-OwnedHired AND Non-ownedAny

Umbrella
Is Umbrella Coverage Needed
Limit:

Inland Marine
Is Inland Marine Coverage Needed?
Coverage Details

Additional Coverages Needed?
Is there a need for any of these coverages?

Employment Practices LiabilityEmployment Benefits LiabilityData BreachProfessional LiabilityPollution LiabilityTenant Legal Liability
Add all necessary documents here

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