Please complete our form and one of team members will reach out to you. Business Insurance - Short Form Types of Insurance Needed* General Liability Workers Compensation Property Equipment Business Auto Business Name*Tax ID # (FIEN)Date Business Opened*Type of organzation*Sole ProperiterLLC (Limited Liability Compnay)CorporationNot-for_ProfitPrimary Contact Name* First Last Cell Phone*Email Business Address (mailing address)* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Description of Business Operations*Please briefly tell us what your company does. Make sure to include any specialty within an industry. For example, if you are a concrete company, please don't simply state "construction" as your industry. We adapt to your specific trade. Number of Employees (counting yourself)*12-56-1011-2526-5051-100101-500501-10001001+Annual Payroll (excluding what you pay yourself)*Number of Locations*12345I will email Excel Spreadsheet with ListGross Annual Receipts*Claims? Tell us about any claims including when and how much was paid.If you have loss runs please email to reed@reedinsla.com with your Business Name in the Subject FieldOnce you hit submit you will receive an email with instructions on sending supporting documents
