Commercial Lines Intake Form "*" indicates required fields Lines of Business* General Liability Commercial Property Commercial Auto Workers Compensation Cyber Liability Are you a contractor?* Yes No Only select one. Who have you been working with?*Patrick McBrideRae MaginnisCam PlotnerBusiness DetailsBusiness Name:* DBA (Business Name): Business Entity Type*AssociationCorporationIndividualLimited Liability CompanyPartnershipTrustFEIN / Tax-ID Number:* Contact DetailsContact Person:* Phone Number:*Email:* Mailing Address:* Street Address City 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 State ZIP Code Is Physical Address Same As Mailing Address?* Yes No Physical Address:* Street Address City 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 State ZIP Code Website Address: Brief Description of Operations:*Names and % of Ownership for all Officers:*Full NamePosition% of Ownership Add RemoveYear Business Started:* Number of Years experience:* Estimated Annual Premium: Number of Losses: Number of Employees: Full Time*Number of Employees: Part Time*Estimated Annual Revenue:*Estimated Annual Payroll:*Current Carrier: Time With Carrier Expiration Date: MM slash DD slash YYYY PropertyBuilding value:* Year Built:* Construction Type:* Alarms:*CentralLocalNoneSprinklers*YesNoPartialOccupied Sq Footage: Roof Updated:* Plumbing Updated:* HVAC Updated:* Electric Updated:* Business Personal Property: Property off premises: General LiabilityInsurance Limits:* Professional liability: EPLI: Inland Marine: Business AutoAuto Liability Limits*$1,000,000 CSL$500,000 CSLOtherAttach or ask for VIN’s of each car Add RemoveVehicle Use Add RemoveDriver Full Name Add RemoveDate of Birth Add RemoveDL # Add RemoveWorkers CompensationLiability Limits*$1M / $1M / $1M$500k / $500k / $500k$300k / $300k / $300kOtherClassification Add RemovePayroll Add RemoveOwners Included/Excluded*ExcludedIncludedAdditional Contractor DetailsContractors License # % of work Subcontracted out % of Residential Work % of Commercial Work % of Remodel/Install work % of New Construction Work % of Service/Maintenance Work Do you perform Government/Municipality Work?YesNoCyber DetailsRecord Count (if you're not sure, leave it blank and we'll estimate for you)Number of Employees (if you’re not sure, leave it blank and we’ll estimate for you)MFA in place for remote network access? Yes No Uncertain MFA in place for email access? Yes No Uncertain MFA in place for network admin and other privileged users? Yes No Uncertain EDR tool that includes centralized monitoring? Yes No Uncertain Regularly back up and segregate sensitive data? Yes No Uncertain Email security filtering tool in place? Yes No Uncertain I don’t know the answers to any of these questionsDec Pages / ConsentAdd Dec PagesMax. file size: 39 MB.Consent I agree to The McBride Agency's privacy policy.