Quote Request Form - Hale and Associates

New Business Information Sheet

Entity Name*

Entity Type*

Nature of Business/Operation Description

Mailing Address*

Street Address City State ZIP Code

Name*

Email*

Phone*

Locations

Other States Needed

Federal Employer Identification Number (FEIN)

# Years in Business

Lines of Insurance to be Quoted

Effective Date

Payroll Exposures

Prior Losses

Additional Insureds (ex: landlord)

Last Year’s Sales/Revenue

(if this is a new venture please put Anticipated Sales)

Experience in this line of work