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Contact Name*

Email Address*

Contact Phone Number*

Website

Legal Name

Entity Type

Registered Company Name

DBA

FEIN

Currently Insured?

Mailing Address

Physical Address

Year Built

Square Footage

Roof Type

Description of Business Operations

Owner 1 Name

Owner 1 Percentage Ownership

Gross Receipts

Prior Year Gross Receipts

Estimated Next Year Gross Receipts

Estimated Annual Payroll

# Full Time Employees

# Part Time Employees

Product List

Licensing

Short Bio or LinkedIn Page (Owner)

Types of Insurance Needed/Interested in? Types of Insurance Needed/Interested in? General Liability Products Liability Commercial Property Insurance - Owner or Tenant Workers Comp Commercial Auto or Transportation Life Insurance

Does Your Business: Does Your Business: Sell Other Companies Products Manufacture Your Own Products Work With A 3rd Party Manufacturer

If You Work With A 3rd party manufacturer, Please List Who

Desired Building Loss $ Coverage Amount (sq footage x 100)

Desired Income Loss Protection $ Coverage Amount

Desired Business Personal Property $ Coverage Amount

Desired Indoor Grow Equipment/MFG Equipment $ Coverage Amount

Desired Outdoor Grow Equipment $ Coverage Amount

Desired Tenants Improvements $ Coverage Amount

Desired Completed Stock / Sitting Inventory $ Coverage Amount

Desired Goods in Process / Sitting Biomass Owned $ Coverage Amount

Desired Non-Owned Stored Product $ Coverage Amount

Desired Non-Owned In Transit Product $ Coverage Amount

Desired Vegetative & Flowering / Growing Plants $ Coverage Amount

Desired Harvested Plant $ Coverage Amount