All required fields are marked with a red asterisk *. For all other fields, only complete the information that is applicable to the insurance we are quoting for you.General Business InformationName* First Last Email* Phone*Business Name*Business Address* Street Address Address Line 2 City State 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 ZIP Code Entity Type* Individual/Sole Proprietor/Single Member LLC C Corporation S Corporation Partnership LLC - C LLC - S LLC - P Trust/ estateFEIN NumberNumber of Years in Business*Please select one.Less Than 1123456789101112131415161718192020+Since your business is less than one year old, how many years’ experience do you have in this industry?*Please select one.Less Than 1123456789101112131415161718192020+Number of Employees*Gross Annual Sales*Please note that payroll amounts should be as accurate as possible, as General Liability and Worker’s Compensation policies are audited at the end of the term from a premium standpoint.Annual Payroll Amount*1. Do not include payroll for owners, officers, partners, or members of the company. 2. Please note that payroll amounts should be as accurate as possible, as General Liability and Worker’s Compensation policies are audited at the end of the term from a premium standpoint.Brief Description of Business Activities or Website Address*Current Insurance Carrier*Current Insurance Policy Expiration Date*Number of Years with Current Insurance Carrier*How many claims have you filed in the last 3 years?*Please select one.0123456789101112131415161718192020+Were you referred to Shafer Insurance Agency by anyone?YesNoPlease share the name of the person who referred you.Business Property CoverageYear Building was BuiltNumber of Stories of BuildingYear of Electrical UpdatesYear of Plumbing UpdatesYear of HVAC UpdatesAge of RoofSquare Footage of the BuildingAmount Needed to Cover BuildingAmount Needed to Cover ContentsBusiness Auto CoverageHow would you like to submit your vehicle information?Please Choose OneI will upload a document with the information.I will type out the information.Vehicle ListMust include the make, model, and VIN for each vehicle. Accepted File Types: .xls, .pdf, .jpeg, .png or .doc Drop files here or Select filesAccepted file types: xls, pdf, jpeg, png, doc, Max. file size: 300 MB.Vehicle ListMust include the make, model, and VIN for each vehicle. Accepted File Types: .xls, .pdf, .jpeg, .png or .docHow would you like to submit your driver information?Please Choose OneI will upload a document with the information.I will type out the information.Driver ListMust include the First Name, Last Name, DOB, Driver’s License #, and State of Issuance for each driver. Accepted File Types: .xls, .pdf, .jpeg, .png or .doc Drop files here or Select filesAccepted file types: xls, pdf, jpeg, png, doc, Max. file size: 300 MB.Driver ListMust include the First Name, Last Name, DOB, Driver’s License #, and State of Issuance for each driver. Accepted File Types: .xls, .pdf, .jpeg, .png or .docBusiness Equipment CoverageHow would you like to submit your equipment information?Please Choose OneI will upload a document with the information.I will type out the information.Equipment ListMust include the make, model, serial number, and value of each piece of equipment. (For contractors only.) Accepted File Types: .xls, .pdf, .jpeg, .png or .doc Drop files here or Select filesAccepted file types: xls, pdf, jpeg, png, doc, Max. file size: 300 MB.Equipment ListMust include the make, model, serial number, and value of each piece of equipment. (For contractors only.) Accepted File Types: .xls, .pdf, .jpeg, .png or .docWhen you become a Shafer Client and refer someone to us, we’d like to help the community in your honor. Please pick one of these non profits and we’ll make a donation when a referral is made. United Way of Greater Knoxville Young Williams Animal Center Second Harvest Food Bank Salvation Army Friends of TN Babies with Special NeedsUntitled* I agree that the information I have provided is accurate for my company and that I have the authority to provide this information.CAPTCHA
