Business Insurance – Legacy Partners MN

Legal Business Name *

Entity *

Address Of Business

Street Address

Apartment # or Suite #

City

State

Zip

Year Incorporated

State of Incorporation

Contact Person's Name *

First

Middle

Last

Contact Person's Address

Street Address

Apartment # or Suite #

City

State

Zip

Contact Person's Date of Birth

Contact Person's Social Security Number

Contact Person's Phone *

Contact Person's Email *

Email

Confirm Email

Current Carrier

Policy Number

How long have you been with the current carrier?

Inception Date of Current Policy

Expiration Date of Current Policy

Building Status

Year Built

Total Building SF

Total SF Occupied

Estimated Gross Sales Per Year

Estimated Value of Equipments

Number of Employees

Payroll Amount

Do you offer Work Comp?