Commercial Insurance

Quote Request Intake Form

Thank you for considering Acuhawk Insurance Solutions for your insurance needs. Please answer the questions in this form to the best of your ability for the most accurate quote.

Protecting your business is our business!

Basic Business Information

Legal Business Name *

DBA Business Name (if applicable)

Entity Type *

Date Business was Established *

Tax ID Number (TIN) *

Work Phone Number

Business Address *

Mailing Address (if different)

Business Website

Describe Your Business *

Is This Business a Subsidiary? *

Yes

Do You Own Other Businesses? *

Yes

Additional Information About Other Business(es)

Owner Information

First Name *

Last Name *

Email *

Phone *

Date of Birth *

Social Security Number

Driver's License Number *

Main Contact Person's Information

Is this Owner the Main Contact Person? *

Yes

Are There Additional Owners?

Yes

Please Provide Details for the Additional Owner(s)

Financial Information

Description of Products/Services Offered

Projected Annual Revenue/Sales *

Projected Annual Owner Payroll/Income

Number of Full Time Employees (W2) *

Projected Annual Full Time Payroll (W2)

Number of Part Time Employees (W2) *

Projected Annual Part Time Payroll (W2)

Number of 1099 Contractors *

Projected Annual 1099 Payments

Facility Details

Do You Operate Out of Your Home? *

Yes (Clients Come to My Home)

Yes (Clients Don't Come to My Home)

Square Footage Used for Business

Do You Operate Out of a Commercial Space? *

Yes - Rented/Leased Space

Yes - Owned Space

Building Information

Additional Interest Information (if Needed)

Commercial Auto Use

Will autos be used in the course of business?

Yes - Used for transporting goods and/or other people

Yes - But not for transporting goods and/or other people

How Are the Vehicles Insured Currently?

Please provide the names, driver's licenses, dates of birth, and driving record details for anyone who may drive the vehicle(s)

Please provide the Year/Make/Model/VINs for Vehicles Used (Unless Declarations Page is Provided)

Insurance History & Claims

Have You Held Business Liability Insurance in the Past? *

Yes - it is still active

Yes - it is no longer active

Prior/Current Insurance Details

Current Commercial Declarations Pages (If Available)

Please include files for all products (General Liability, Professional Liability, Workers Comp, Commercial Auto, Business Property, etc) Multiple files are allowed.

Commercial Loss Runs (If Available, Obtain From Prior Carrier)

This is a letter from your previous/current (carrier(s) demonstrating no losses for the last 5 years or since inception. No prior insurance? We will help with a no loss letter that will be needed.

Any past, pending, or alleged claims or lawsuits? *

Yes

Payment Preferences

& Additional Notes

Please indicate the desired frequency, modes of payment, and billing preferences.

Additional Requests, Details, or Questions

By submitting this form, I consent to be contacted by Redinbaugh Enterprises, LLC, its subsidiaries, and representatives at any of the contact information provided and agree to the company's Privacy Policy and Terms and Conditions.

Thank You!

We appreciate your time in completing this form. Please note that additional information may be needed depending on your specific industry. We look forward to the opportunity to serve you and will be in touch with an update within 1-2 business days.

Need something beforehand? Please contact our office at:

531-222-2120

[email protected]