[Breathe – Business Owner’s Package Quote]

Industry
Hidden
NAICS
Primary Business Description*
Business Name
Do you have a DBA Name (Doing Business As)*
What is your DBA Name?
Business Website
Business Entity Type*
- Individual (Sole Proprietor)
- Partnership
- Corporation
- LLC
- Other
What is the Business Tax ID?
What is your Social Security #?
What Entity Type is the Business?
What is the Business Tax ID or your Social Security #?
Business Physical Address
Street Address City State ZIP Code
Business Mailing Address
Same as previous

Street Address Address Line 2 City State ZIP Code
Is the business recently formed?*
What year did the business start?
How many years of experience do you have?
What is the total annual gross revenue or sales?
What is the first-year revenue or sales goal?
Briefly describe business operations*
Has any policy been cancelled or non-renewed in the past 3 years?
- Yes
- No
Describe reason for cancellation or non-renewal
Did you have any claims in the past 5 years?
- Yes
- No
Describe claims in the last 5 years with amount paid for each loss or claim.
Do you own 50% or more in another business?
Please describe other business ownership
Business Location Information

Do you lease or own the building your business occupies?
- Lease
- Own
- Home Based
What is the total square feet of the building?
What is the total square feet occupied?
Do you have clients come to your home?
Is the building older than 20 years?
What year was the building built?
What type of roof covering?
Has the roof been replaced?
What year was the roof replaced?
Has the electric been updated?
What year the electrical last updated?
What year was the heating/AC last updated?
Has the plumbing been replaced?
What year the plumbing updated?
What is the distance of the nearest fire hydrant in feet?
Does the building have working fire sprinklers?
- Yes
- No
Is there a centrally monitored fire alarm?
- Yes
- No
Is there a centrally monitored burglar alarm?
- Yes
- No
Insurance Coverage Selection

Your Information