Apply Business Insurance | Simple Insured

Legal Business Name *

Please enter a valid Legal Business Name

Doing Business As (DBA) *

Please enter a valid DBA (2-50 characters)

Business Type *

Sole Proprietorship

Partnership

LLC

Corporation

Non-Profit

Other

Please select a Business Type

Other Business Type *

Please enter a valid Business Type (2-50 characters)

Business Category *

Retail / E-commerce

Professional Services

Construction / Contracting

Manufacturing

Transportation / Logistics

Healthcare / Wellness

Hospitality / Food Services

Real Estate

Other

Please select Business Category

Other Business Category *

Please enter a valid business category (2-50 characters)

Business Activities *

Please enter a valid Business Activities (2-50 characters)

Business start date *

Please select your Business start date

Number of full-time employees *

Please enter a valid number of employees

Number of part-time employees *

Please enter a valid number of employees

What types of insurance coverage are you looking for? *

Desired policy effective date *

Please select your Desired policy effective date

Estimated annual revenue ($)*

Please enter valid Estimated annual revenue

Estimated annual payroll ($)*

Please enter valid Estimated annual payroll

Any vehicles used for business purposes? *

Yes

No

Please select if Any vehicles are used for business purposes?

Do you operate from a commercial location or home office? *

Commercial Space

Home Office

Please select work location

Do you store or handle customer data or payment info? *

Yes

No

Please select customer data option

Do customers visit your business premises? *

Yes

No

Please select Customer Visit option

Do you ship or deliver products? *

Yes

No

Please select shipment option

Do you handle or store hazardous materials? *

Yes

No

Please select hazardous material option

Do you currently have business insurance? *

Yes

No

Please select insurance status

Current Carrier *

Please enter a valid Current Carrier (2-50 characters)

Policy expiration date *

Please select your Policy expiration date

Have you had any business insurance claims in the past 5 years? *

Yes

No

Please select work location

Date of loss *

Please select your Date of loss

Type of claim *

Please enter a valid claim type (2-50 characters)

Amount paid ($)*

Please enter valid Amount paid ($)

Any business bankruptcies or lawsuits in the past 5 years? *

Yes

No

Please select work location

First Name *

Please enter a valid first name (2-50 characters)

Last Name *

Please enter a valid last name (2-50 characters)

Email Address *

Please enter a valid email address

Phone Number *

Please enter a valid phone number

Street Address

Zip Code

City

State

Title / Role *

Please enter a valid Title / Role (2-50 characters)

Mailing Address same as Business Address? *

Yes

No

Please select work location

Additional Notes / Comments Please share any other information that might be helpful for your quote — such as specific coverage needs, current health conditions, or questions about available plans

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