Business Insurance Proposal Request Business Name*Business Contact* First Last Contact Email* Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican 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 RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican 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 RicoQatarRéunionRomaniaRussiaRwandaSaint 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 IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Business Contact Phone Number*Preferred Method of Contact*Office Phone NumberCell PhoneEmailType of Entity*Sole Proprietor (single owner/not incorporated)Partnership (multiple owners/no incorporated/Formal Contract)S CorporationC CorporationLimited Liability Corporation (LLC)Limited Liability Partnership (LLP)OtherType of Business Operation*What your business does.FEIN Number (Tax ID)Date the business began Date Format: MM slash DD slash YYYY What type of insurance are you interested in?* General Liability Business Property (Building) Business Personal Property (i.e. Furniture, Equipment, Tools, Inventory, etc) Business/Commercial Auto Insurance Workers Insurance Inland Marine (ie. Large Mobile Equipment) Professional Liability/Errors and Omissions/Malpractice Cyberliability Employment Practices Pollution Other Let's discuss... Check all that apply - more lines = more discountsDo you currently have business insurance?YesNoName of your current carrier:How many years have you been with your current carrier?Do you own or rent your business' space?*OwnRentWork out of the homeHow many square feet does your business occupy?Gross Annual Receipts*Number of Employees*Number of Owners*Will your owners be included in your workers compensation policy?*YesNoDo your employees use their own vehicle for work?*YesNoDoes your business own or lease vehicles?*YesNoTotal number of cars owned/leased by businessHow will you provide us a list of your vehicles/machinery?Email a list to adam@sidebarinsurance.comGive to us over the phoneHow many employees are listed on your current insurance policy?Gross Salaries paid to employeesTotal amount of salaries paid to your employeesHow will you provide us a list of your drivers and driver's license information?Email a list to adam@sidebarinsurance.comGive to us over the phoneHow will you provide us a list of your prior loss runs?I will scan and email them.I'd like to connect on the phone to planI'll fax them to Adam @ 708-403-4228
