(000) 000-0000
St Louis, MO
We are an Independent Insurance Agency in St Louis, MO., with NO affiliation to Gateway Insurance Company or Gateway Health Plans.
We are an Independent Insurance Agency in St Louis, MO., with NO affiliation to Gateway Insurance Company or Gateway Health Plans.
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General Information
Contact Name
*
Email
*
Phone Number
*
Type of Business
Business Name
Business Phone
Mailing Address
City
State
Zip/Postal Code
County
How did you find our agency?
*
Social Media
Customer Referral
Google Search
Google Ad
Current Insurance Company
Company Name
FEIN #
Current Insurance Coverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Liquor Liability
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
Address
City
State
Zip
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Frame
Brick Veneer
Stucco
Metal
Concrete
Stories
# Basements
Sq. Footage
Burglar Alarm
Yes
No
Building Value
Contents
Other Property (specify)
Insurance Information
Business Personal Property Amount
Annual Gross Sales: (before taxes)
If Liquor Liability Required-Gross Annual Liquor Sales?
Annualized Payroll
Cost of any Subcontracted Work
Liability Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
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