Commercial New Business Form "*" indicates required fields Step 1 of 10 10% Start Here:Name:* First Last Email:* Enter Email Confirm Email Phone:*Date Quote Needed:F.E.I.N. or S.S. #:Business Name:*Business Start Year:*Website:Current client of DiStefano Insurance?* Yes No Currently have insurance?* Yes No Choose your coverage type?*Select all that apply: Property / Equipment / Tools Liability Auto Umbrella Cyber Other Select All Business History: These fields cannot be left blank. Use approximate if not sure. If no coverage put "none".Current Carrier:*Current Premium:*Years of Industry Experience:*What does the business do?*Any claims in the last 3 years? If yes, provide details & amounts paid.* Property Coverage: Some fields cannot be left blank. Use approximate if not sure. If no put "none".Do you need building coverage?* Yes No Do you have more than one location?* Yes No Business Personal Property (BPP) Limit:*Personal Property of Others (PPO) Limit:*Scheduled Equipment (total limit of ins.):Small tools (items under $2500, any one tool):Rented / Leased Equipment:Roof Update Year:*Electrical Update Year:*HVAC Update Year:*Plumbing Update Year:*Primary Business Address:* Street Address 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 Additional Location Information: Add multiple locations here. Click "+" to add another. Use approximate if not sure.Secondary Business Address(es):*Street AddressCityStateZIP Add RemoveBuilding History:*Roof Update YearElectrical Update YearHVAC Update YearPlumbing Update Year Add Remove Liability Coverage: These fields cannot be left blank. Use approximate if not sure. If no put "none".Number of Full Time Employees:*Number of Part Time Employees:*Total Payroll:*Total Sales:* Business Auto: Add multiple vehicles & drivers here. Click "+" to add another.Vehicle History:*YearMakeModelVIN # Add RemoveDriver History:*Driver Name(s)Driver's License NumberDriver's Date of Birth Add RemoveHow far do your vehicles travel one way?*Select approximate radius50 miles or less100 miles200 milesOver 500 miles Umbrella Coverage:Select Umbrella limit?*SelectNo (Reject Umbrella Coverage)$1 Million$2 Million$3 Million$4 Million$5 Million Cyber Coverage: Click "+" to add more than one website.Need Cyber Coverage?* Yes No What are your gross sales?*Do you use Multi-factor Authentication (MFA)?* Yes No Do you have antivirus software?* Yes No Web Address(es):* Add Remove Additional Coverage Options:Let us know what other coverages you're looking to secure. Thanks for your time and consideration.How did you hear about us?*SelectI'm a current DiStefano customerCustomer ReferralGoogle SearchGoogle AdFacebookDigital SignSponsorship BannerMailOtherWho referred you?What is your motivation for seeking outside insurance options? What would you like us to try and fix?Upload your policy documents and supplemental documents here: Drop files here or Select files Max. file size: 39 MB.
