Business Application for Commercial Insurance Step 1 of 4 25% Contact Person's Name(Required) First Last Cell Phone Number(Required)Email Address(Required) Business Legal Name(Required) Number of Owners(Required)1 Owner2 Owners / Partners3+ Owners / PartnersOrganization Type(Required)Individual / Sole ProprietorLimited Liability Corp (LLC)Limited Liability Partnership (LLP)Incorporated (Corp)OtherFEINBusiness Website Address Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What coverage is your business interested in?(Required) General Liability Property Coverage Commercial Auto Liability Worker's Comp Professional Liability Excess Liability / Umbrella Check all that applyWhat has you shopping for insurance?(Required)Please check all the apply New Venture Price Bad Claims Experience Poor Customer Service Experience No local representation Business ExperiencePlease provide the following information regarding your business experience. DO NOT include payroll for owner(s) below.Year Business started(Required)How many years of industry experience(Required)Estimated Gross Sales / Revenue for the upcoming 12 months:(Required)Estimated Payroll for the upcoming 12 months:(Required)Number of employees (including W2 & 1099)(Required)Cost of Subcontractors (including labor & materials):(Required)Occupied Sq ft:(Required) Do you have insurance currently?(Required) Yes No Name of your current insurance provider:(Required) Expiration Date:(Required) Briefly describe your business operations:(Required) How did you first hear about us?(Required) Current Customer Family/Friend Referral Channel Partner Referral (Mortgage Broker, Realtor, Other Insurance agent) Google Search Social Media Post (Facebook, Instagram, Twitter) Local Event Other Consent(Required) I consent & agree to the following:The application information is true and correct to the best of my knowledge. By submitting this request you are authorizing My Insurance Group, its affiliates and carrier partners the access to pull the necessary reports (i.e. claims, credit, and loss history) to confirm the data submitted. Submitting your quote request does not constitute a binding confirmation of a new or revised insurance coverage. My Insurance Group is committed to respecting your privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you through phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us.CAPTCHA