Phone: (346) 388-4673
SMS: (346) 423-2500
Fax: (281) 503-7631
Email: services@iwp.agency

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What We Need From You

What is your primary business/industry class?(Required)

Full Legal Name of Business(Required)

Primary Contact Name(Required)

First Last

Your Email(Required)

Your Phone Number(Required)

How was your business formed?(Required)

Corporation (Inc.)

Limited Liability Co. (LLC)

Partnership (Ltd.)

Sole Proprietorship (dba)

Other

Date Business Started(Required)

Provide the date business was started and/or acquired.

MM slash DD slash YYYY

Federal Employment Identification Number (FEIN)(Required)

Target Effective Date(Required)

When do you want the policy to be active?

MM slash DD slash YYYY

Website

Leave blank if you have no website.

What states do you work in?(Required)

Please list every state with operations because it is important to let us know if/when you ever work in additional states.

Description of Operations(Required)

Provide as many details as you can explaining the operations of the business.

Mailing Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Physical Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

What Square Footage does your business occupy?(Required)

Just estimate if not sure, even if home office.

What Square Footage is open to the public?(Required)

If working from home, just say 0.

Last 12 months Total Gross Receipts (Sales)?(Required)

What was your total revenue (before expenses) for the last 12 months?

Next 12 Months Estimated Total Gross Receipts (Sales)?(Required)

In many situations these are used to rate policies and can be audited at the end of the year so estimating a figure that is close as possible is best.

Total Annual Payroll (1099 or W2) Employees(Required)

Like sales, these are sometimes used to rate policies and can be audited at the end of the year so estimating a figure that is close as possible is best.

How many employees do you have?(Required)

Most business owners like to call everyone a "subcontractor" because it provides tax savings; however, please don't confuse this with respects to your insurance coverage.

Estimated Total Annual Cost of Insured Sub-Contractors(Required)

These are also sometimes used to rate policies and can be audited at the end of the year so estimating a figure that is close as possible is best.

Estimated Total Annual Cost of Uninsured Sub-Contractors(Required)

These are also sometimes used to rate policies and can be audited at the end of the year so estimating a figure that is close as possible is best.

How did you find our agency?(Required)

Business Development Producer

Email/Mail/Phone

Referral

Google

Facebook

Twitter

Other

Who connected you with our agency?(Required)

This is either the person who referred you to us or the person you are working with already within our agency.

What coverages are you looking for?(Required)

Check all coverages that apply.

General Liability

Commercial Property

Business Auto

Workers Compensation

Commercial Excess Liability

Professional (Errors & Omissions)

Pollution

Equipment (Inland Marine)

Cargo / Ocean Marine

Maritime Employee Liability

Other

Who is your current general liability insurance company ?(Required)

Who is your current general liability premium?(Required)

How much are you currently paying annually?

Whate are your goals and objectives?

What causes you the most stress as it relates to commercial insurance?

File Upload - Policies, Loss Runs, Certificates, Contracts Requiring Coverage, etc.

Providing as many details as possible gives us a stronger profile and usually results in the best outcome!

Max. file size: 5 MB.

Insurance With Purpose Agency, Inc.

Headquartered in Navasota, Texas serving Houston, Woodlands, Montgomery, Magnolia, College Station

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What We Need From You

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