Lessor's Risk Discovery Form Step 1 of 6 - Personal Info 16% Contact Person(Required) First Last Business Name (if different than Contact Person) Organization Type:(Required)Individual/Sole ProprietorLLC/PartnershipCorporationFEIN:Cell Phone(Required)Please provide the best contact phone number where we can reach you to discuss your quote and send you text updates.Email(Required) Please provide the best email address for us to send the insurance quote.Mailing 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 How did you first hear about us?(Required) Current Personal Lines Client Client Referral Google Search Social Media Post (Facebook, Instagram, Twitter) Local Event Other Date Business Started:(Required) Years of Experience:(Required) Estimated upcoming annual gross sales/revenue:(Required) Is this for a purchase?(Required) Yes No Estimated Closing Date:(Required) Month Day Year Purchase PriceProperty 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 % of building that is vacant:(Required) % of building occupied by owner:(Required) Year Built:(Required) Total Building Sq Ft:(Required)Are tenants on Triple-net lease:(Required) Yes No Is there a sign not attached to the building:(Required) Yes No Sign Value: Property DetailsType of property(Required)Residential/HabitationalShopping CenterOffice BuildingOther# of stories:(Required)Year the ELECTRICAL was updated(Required) Type of ELECTRICAL(Required)Circuit BreakerFuse BoxKnob & TubeUnknownYear the PLUMBING was updated(Required) Type of PLUMBING(Required)PVC/PEXCopperGalvanizedLeadUnknownYear the HVAC was updated(Required) Type of HVAC(Required)Central AC & Gas HeatingCentral AC & Electrical HeatingWindow Unit - Cooling & HeatingWindow Unit - Cooling OnlyWall FurnaceOtherYear the ROOF was updated(Required) Type of ROOFING(Required)Comp ShinglesFlat - Built up SmoothFlat - Built up Tar & GravelMetal RoofOther / Not SureType of Alarm(Required) None Local Central Monitored % of Building Sprinklered(Required) Tenant InformationList of tenant(s) in the propertyTenant Name / Type of Business / Sq Ft / Monthly Rent(Required) Add Remove Authorization(Required) I agree & consent to the following:All the 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.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
