Salues Insurance Advisory

Legal Business Name *

DBA (If any)

Entity Type *

If Other, specify *

FEIN / Tax ID *

Year Business Started *

Business Phone *

Business Email *

Is this also the mailing address? *

Yes

No

Mailing Address (if different) *

Primary Contact Name *

Title / Role *

Contact Phone *

Best time to reach you

Preferred Contact Method *

Website

Primary Industry / Type of Business *

Do you perform work at client locations? *

Yes

No

Do you collect COIs from subs? *

Annual Gross Revenue (last 12 months) *

$

Estimated Gross Revenue (next 12 months) *

$

Percent subcontracted (if any) *

Number of Employees — Full-Time *

Part-Time *

Owners/Officers only? *

Number of Locations *

Do you currently have General Liability coverage? *

Any coverage lapse in past 3 years? *

Current / Prior Carrier *

Policy Expiration Date *

Current GL Limits

Any GL claims in the past 5 years? *

If Other Laibility, specify *

Additional Insured required? *

Additional Insured Name *

Additional Insured Address *

How did you hear about Salus Insurance Advisors? *

Who referred you? (ONLY if Referral selected) *

Referral Type (ONLY if Referral selected) *

Full Name *

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Salus Insurance Advisors

SECTION 1 — Business Information

SECTION 2 — Business Address

SECTION 3 — Primary Contact

SECTION 4 — Business Operations

SECTION 5 — Payroll & Revenue

SECTION 6 — Locations

SECTION 7 — Prior Insurance History

SECTION 8 — Claims History

SECTION 9 — Additional Exposures (check all that apply)

SECTION 10 — Requested Coverage Limits

SECTION 11 — How did you hear about us?

SECTION 12 — Required Documents

SECTION 13 — Authorization & Signature

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