297 NW 3rd St
Prineville, OR 97754
Phone
541-447-6372
Send Us
a Message
Start
Quote

297 NW 3rd St
Prineville, OR 97754
Phone
541-447-6372
Send Us
a Message
Start
Quote

About
Us
Personal
Insurance
Business
Insurance
Life, Health
& Benefits
Client
Services
297 NW 3rd St
Prineville, OR 97754
Phone
541-447-6372
Send Us
a Message
Start
Quote

About
Us
Personal
Insurance
Business
Insurance
Life, Health
& Benefits
Client
Services
297 NW 3rd St
Prineville, OR 97754
Phone
541-447-6372
Send Us
a Message
Start
Quote

WBTO Commercial Intake

Proposed effective date

MM slash DD slash YYYY

Name

First Last

How did you hear about us?

Business name

DBA name

Type

Individual

Sole Propietor

Partnership

Corporation

LLC

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Locations

Nature of business

Please describe what your business does in detail.

Date business entity established

MM slash DD slash YYYY

# Years total industry experience

What states will you work in?

Annual Income

Business Phone

Business Fax

Business Email

Cellphone

Website

Federal Tax ID No

Hours of Operation

PERSONAL INFORMATION

Owner's name

First Last

% of ownership

Active?

Yes

SSN

DOB

MM slash DD slash YYYY

Owner's name

First Last

% of ownership

Active?

Yes

SSN

DOB

MM slash DD slash YYYY

Owner's name

First Last

% of ownership

Active?

Yes

SSN

DOB

MM slash DD slash YYYY

Ever declared bankruptcy?

Yes

Any lawsuits pending against you?

Yes

GENERAL LIABILITY

General Liability

No employees

Subcontractors used

Yes

Total Sub Contractor Cost

Seasonal operations

Yes

Safety programs

Yes

Please describe in detail safety measures adhered to:

List your gross sales for the last 3 years (Year)

New venture

Yes

Estimated gross sales for the current year?

Do you want business income coverage?

Yes

Amount per month

Prior Insurance

New venture

Have you ever been cancelled or non-renewed in the last three years?

Yes

If yes, explain

Request:

Declaration pages for all lines

Loss runs for all lines

WOULD YOU LIKE A QUOTE FOR:

Business Auto

Yes

Property

Yes

Equipment & Tools

Yes

Work Comp

Yes

Please List Year, Make, Model, and VIN for all vehicles

General Liability

Yes

Professional Liability

Yes

Employee Benefits

Yes

Umbrella/excess

Yes

Enviro/Pollution

Yes

Bond

Yes

CYBER

Yes

EPLI

Yes

Comments

INLAND MARINE - BUSINESS EQUIPMENT & TOOL COVERAGE - off premises coverage

Declined coverage

Inventory $

Office Equipment $

Property of Others $

BUSINESS PERSONAL PROPERTY EQUIPMENT & TOOL COVERAGE - on premises only

Declined coverage

Inventory $

Office Equipment $

Property of Others $

List equipment Valued over $1000 per item

Year

Make & Model

Serial #

Value $$

Workers compensation- Current Insurance:

Trade/Job description

# of employees

Estimated anual payroll

Residence State

Work state

Trade/Job description

# of employees

Estimated anual payroll

Residence State

Work state

Coverage desired for owners?

Yes

If yes, provide Annual wage

Do any employees predominantly work at home?

Yes

If yes, explain

Business Auto

Declined

Current insurance

Hired/Non owned

Yes

Personal Auto Insurance

Yes

Driver other car coverage

Yes

Declined

Designated name insured

Yes

Declined

Driver

DOB

SSN

DL # and State

Tickets/Accidents

Vehicle Information

Year

Make & Model

VIN

Current Value $

Radius of operation

0-50 miles

51-100 miles

101-200 miles

201-500 miles

Over 500 miles

Special equipment attached to any vechile?

Yes

Which vehicle?

Type of equipment

Value $$

Included in vehicle value?

Building coverage

Building #1 Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year Built

# of Units

Sq. Feet

# Stories

Owner or Tenant?

Sq Ft You Occupy?

PC Class

Construction

Pole

Frame

Masonry

Steel

Other

If other

Distance to Fire Hydrant

Roof Material

Tenant Biz Description

Cost of Reconstruction

Heat Type

Cooling

Plumbing

Electrical

Year of updates

Roof

Electrical

Heating

Plumbing

Burglar Alarm

Yes

Type

Fire Alarm

Yes

Type

Sprinklers

Yes

Building #2?

Yes

Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year Built

# of Units

Sq. Feet

# Stories

Owner or Tenant?

Sq Ft You Occupy?

PC Class

Construction 2

Pole

Frame

Masonry

Steel

Other

If Other

Distance to Fire Hydrant

Roof Material

Tenant Biz Description

Cost of Reconstruction

Heat Type

Cooling

Plumbing

Electrical

Year of Updates

Roof

Electrical

Heating

Plumbing

Burglar Alarm

Yes

Type

Fire Alarm

Yes

Type

Sprinklers

Yes

Professional Liability

Do you have Prof Liability?

Yes

Current carrier

Effective Date

MM slash DD slash YYYY

Current limits

Current premium

Enviromental/Pollution

Do you have Enviro/Pollution Liability?

Yes

Current carrier

Effective Date

MM slash DD slash YYYY

Current limits

Current premium

Umbrella/excess

Do you have Umbrella/Excess?

Yes

Current carrier

Effective Date

MM slash DD slash YYYY

Current limits

Current premium

Recreational Toys

Yes

EPLI

Do you have EPLI?

Yes

Current carrier

Effective Date

MM slash DD slash YYYY

Current limits

Current premium

Employee Benefits Liability

Do you have Employee Benefits Liability?

Yes

Current carrier

Effective Date

MM slash DD slash YYYY

Current limits

Current premium

Cyber Liability

Do you have Cyber Liability?

Yes

Current carrier

Effective Date

MM slash DD slash YYYY

Current limits

Current premium

Get Started With Insure Pacific Agency

Our team is one click or call away from helping you, your family, or your business with an insurance experience you'll actually enjoy.

Call Us Today!

541-447-6372

Start My Quote

Main Agency Phone

541-447-6372

Address

541-447-6372

297 NW 3rd St
Prineville, OR 97754

Please Write Us a Google Review!

Currently Licensed In

Alabama, Arizona, California, Colorado, Georgia, Idaho, Nevada, Oregon, South Dakota, Texas, Utah, and Washington

License # 0L89671

Made with in Indianapolis by Awesurance.

WBTO Commercial Intake

PERSONAL INFORMATION

GENERAL LIABILITY

Prior Insurance

WOULD YOU LIKE A QUOTE FOR:

List equipment Valued over $1000 per item

Vehicle Information

Building coverage

Year of updates

Year of Updates

Professional Liability

Enviromental/Pollution

Umbrella/excess

EPLI

Employee Benefits Liability

Cyber Liability

Get Started With Insure Pacific Agency

Call Us Today!

541-447-6372

Main Agency Phone

Address

Please Write Us a Google Review!

Follow Us

Currently Licensed In