Business Information Update - Executive Choice Insurance Solutions

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Full Name:*

First Last

Business Legal Name (and DBA, if applicable):

Phone Number:*

Email Address:*

Mailing/Correspondence Address:*

Street Address Address Line 2 City State ZIP Code

Are there any significant changes in your business operation since we last spoke? (Merger/Acquisition, New lines of business, new categories of operation, etc.)

How many W-2 employees does your team currently have?

What is your projected total W-2 payroll for the upcoming 12 months?

What is your projected gross revenue for the upcoming 12 months?

What is your projected total paid to subcontractors or 1099 team members for the upcoming 12 months? (if applicable)

If you have acquired any new property, added locations, or made other changes that effect your insurance needs, please detail them here.

Do we need to add any additional insured's to your policy? (Bank, landlord, new contracts, etc)

Is there anything else that we need to know now to make sure your insurance program is exactly what you need?

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