subject_line
John Galt Insurance Agency
CNR Application
Company Information
Company Name
*
0/78 characters
DBA Name
0/78 characters
FEI/EIN Number
(First 2 digits)
FEI/EIN Number
(Next 7 digits)
Business Type
Corporation
Individual
Joint Venture
LLC
Not for Profit Organization
Partnership
Sub-chapter S Corporation
Trust
Address
*
0/50 characters
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Salutation
*
Mr
Ms
Contact's First Name
*
Contact's Last Name
*
Contact's Title
*
Accountant
Admin
Assistant
Asst PM
Bishop
Brother
CEO
CFO
Controller
Co-Owner
DIR
GM
HR
IT
MGR
Office MGR
Owner
Partner
Pastor
PM
Pres
Principal
Rabbi
Rev
Sec
Sister
Tres
VP
Contact's Office
Phone Number
*
Contact's
Ext.
Contact's Cell
Phone Number
Contact's Fax
Number
Email Address
*
Company's Web Site
0/500 characters
Description of your business
Describe the nature of your business
*
0/300 characters
Are you a Daycare
or Private School?
*
Yes
No
How many children
do you currently
have enrolled?
*
Do you currently pay in
excess of $10,000 annually
for all of your business
insurance combined?
*
Yes
No
Unknown
What is the estimated
premium amount
that
you are currently paying
for all of your business
insurance?
*
What is your company's
estimated
annual gross
revenue per year?
*
What is your company's
estimated
annual payroll
amount per year?
*
How many total
employees do you
have?
*
How many of your
employees are FT?
*
How many of your
employees are PT?
*
How many are
1099 employees?
*
Does your company currently offer Health
Care, Life, Dental, Disability or a 401k plan
to your employees?
*
Yes
No
Unknown
How many of your total
employees are currently
enrolled in your company's
benefit plans?
*
What percentage of the premium
does your company pay for the
employee?
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
What percentage of the premium
does your company pay for the
employee's dependents?
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Do you have any
company vehicles?
*
Yes
No
How many?
Any insurance claims in the past year?
*
Yes
No
Unknown
Explain those claims in detail
+
-
Insurance information
Type of coverage
Amount of coverage requested
Boiler & Machinery (BMAC)
Amount of coverage requested
Amount of coverage requested
Business Owner's Policy (BOP)
Amount of coverage requested
Amount of coverage requested
Commercial Auto (CA-S)
Amount of coverage requested
Amount of coverage requested
Commercial E&O (CE&O)
Amount of coverage requested
Amount of coverage requested
Commercial Flood (CFLO)
Amount of coverage requested
Amount of coverage requested
Commercial Package (PCKG)
Amount of coverage requested
Amount of coverage requested
Commercial Umbrella (UM-S)
Amount of coverage requested
Amount of coverage requested
Commercial Wind (CWIN)
Amount of coverage requested
Amount of coverage requested
Cyber Liability (CYBE)
Amount of coverage requested
Amount of coverage requested
Difference in Conditions (DICP)
Amount of coverage requested
Amount of coverage requested
Directors & Officers (DIRL)
Amount of coverage requested
Amount of coverage requested
Equipment Floater (FLTR)
Amount of coverage requested
Amount of coverage requested
General Liability (GL-S)
Amount of coverage requested
Amount of coverage requested
Glass & Sign (GLAS)
Amount of coverage requested
Amount of coverage requested
Inland Marine (INLA)
Amount of coverage requested
Amount of coverage requested
Liquor Liability (LIQL)
Amount of coverage requested
Amount of coverage requested
Pollution Liability (POLL)
Amount of coverage requested
Amount of coverage requested
Property (PROP)
Amount of coverage requested
Amount of coverage requested
Workers' Compensation (WC-S)
Amount of coverage requested
Amount of coverage requested
Other
Amount of coverage requested
Amount of coverage requested
If you indicated "
Other
", please explain
Policy Renewal Date
+
Preferred Appointment Date
+
Appointment Time
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
Attach all pertinent documents here (Files 1-10):
🛈
Attach all pertinent documents here (Files 11-20):
🛈
Attach all pertinent documents here (Files 21-30):
🛈
Internal use only
Appointment Date
+
Appointment Time
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
Type of appointment
In Person
Phone
Email
TM Rep
Don M
Michael M Sr.
Agent
Adam B
Alan A
Amanda C
Bart M
Chase F
Connor M
Daniel L
Donald H
Gannon C
Hermond C
Ivan G
James H
Jay N
Jim S
Jose B
Kendra M
Laura S
Marcos G
Mathew H
Michael M
Ricardo R
Sean O
Trae W
Lead source
*
Incoming email
Incoming phone call
Internal / External referral
Internal / External seminar
John Galt Website
Spreadsheet from Don M.
Telemarketing - Phone call
Telemarketing - Email
Telemarketing - Mailer
Notes
0/1500 characters