Legal Business Name *

DBA (if different)

Address

Business Address *

City *

State *

Postal Code *

Years in Business *

Website

Contact Name/Title *

Phone *

Email *

Business Entity Type *

Operations

Describe Business Operations *

Percentage of Revenue From

Equipment Sales *

Service / Repair *

Parts / Accessories *

Rental Equipment *

Other

Do you manufacture or modify products? *

Do you sell online? *

Any subcontracted work? *

Locations & Property

Number of Locations *

Total Square Footage *

Do you own or lease the building? *

Any outdoor storage? *

Security Protections in Place *

Alarm System

Cameras

Fencing

Fire Sprinklers

Employees

Total Number of Employees *

Number of Mechanics/Technicians

Annual Payroll *

Any seasonal employees? *

Do employees drive company vehicles? *

Insurance History

Current Insurance Carrier *

Current GL Limits *

Expiration Date *

Any claims/losses in past 5 years? *

If yes, please describe below

Claims / Losses in the Past 5 Years

Has coverage ever been cancelled or non-renewed? *

Revenue Information

Annual Gross Sales *

Estimated Annual Payroll *

Estimated Subcontractor Cost *

Estimated Rental Receipts (if applicable):

Products & Services

Brands Sold/Serviced *

Do you repair customer equipment? *

Any welding/fabrication work? *

Any mobile repair/service operations? *

Any equipment demonstrations off-site? *

Additional Coverages Needed

Requested Limits

Desired GL Limit *

Additional insureds needed? *

Certificate holders required? *

By checking this box, I consent to receive text messages from Clearview Insurance Agency LLC regarding your insurance quote request. Message frequency varies, message & data rates may apply.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Clearview Insurance Agency LLC at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.