Brief Description of Business Operations *
Years in Business *
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New / Startup
Less than 1 year
1-2 years
3-5 years
6-10 years
11-20 years
20+ years
Business Entity Type
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Sole Proprietorship
Partnership
LLC
Corporation
S-Corporation
Nonprofit 501(c)(3)
Other Nonprofit
Trust
Joint Venture
Annual Gross Revenue *
Select
Under $250,000
$250,000 - $500,000
$500,000 - $1 million
$1 million - $2.5 million
$2.5 million - $5 million
$5 million - $10 million
$10 million - $25 million
$25 million - $50 million
$50 million+
Total Employees
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Owner Only (0 employees)
1-5 employees
6-10 employees
11-25 employees
26-50 employees
51-100 employees
101-250 employees
250+ employees
Any claims in the past 5 years?
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No claims
1-2 claims
3-5 claims
More than 5 claims
Has coverage been cancelled or non-renewed?
Select
No
Yes - Within past 3 years
Yes - Over 3 years ago
If claims, please briefly describe:
Any upcoming changes to your business?
Preferred Contact Method
Select
Phone Call
Email
Text Message
Video Call (Zoom, Teams)
Any method is fine
Best Time to Reach You
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Morning (8am-12pm)
Afternoon (12-5pm)
Evening (after 5pm)
Anytime
How did you hear about us?
Select
Google Search
Referral - Existing Client
Referral - Business Partner
Referral - Friend/Colleague
LinkedIn
Trade Association
Other
What is the primary goal of this assessment?
Additional Comments or Questions
