Business Discovery Form – Goosehead Insurance

Step 1 of 10

10%

What type of insurance are you looking for?(Required)

BOP

Auto

Workers Comp

Umbrella

Lessors Risk Property

Small Business Property

Apartment Buildings

HOA

Inland Marine

Flood

Builders Risk

Events

Directors & Officers

Errors & Omissions

Cyber

Employee (EPLI)

You can choose multiple lines of business.

Requested Policy Effective Date(Required)

Month

Day

Year

Entity Type(Required)

Legal Business Name(Required)

Year Business Started(Required)

Please enter a number from 1800 to 2099.

DBA

Mailing Address(Required)

Street Address Suite or Unit Number City State ZIP Code

Contact Number(Required)

Email(Required)

Website

Annual Gross Revenue(Required)

Business Owner: First Name(Required)

Last Name(Required)

Business Owner's DOB(Required)

Month

Day

Year

Married or Single(Required)

Married

Single

Business Owner's Home Address(Required)

Street Address Suite or Unit Number City State ZIP Code

What Does Your Business Do?(Required)

Total Number of All W2 Employees(Required)

Please enter a number from 0 to 1000.

Total Salary of All W2 Employees(Required)

Please enter a number from 0 to 99999999.

Total Losses

If you had any losses for this business, please list the type(s) of loss, year claimed, and amount claimed.

Are you currently insured?(Required)

Yes

What is the carrier’s name, how many years, and what lines of insurance?(Required)

Please provide the addresses of all buildings needing insurance, starting with the primary building.

Locations

Address	Owned or Rented?	Actions

There are no Locations.

Maximum number of locations reached.

Would You Also Like to Quote Auto

Yes

Does the applicant carry a General Liability or Business Owner policy?(Required)

If yes, enter name of carrier. If no, enter "no."

Does the applicant carry a Personal Auto policy?(Required)

Yes

Has the applicant carried continuous auto insurance for the prior 12 months?(Required)

If so, enter carrier name and limits.

Are state or federal insurance filings or an MCS-90 required?(Required)

Yes

Does the applicant have a USDOT Number? If so, what is it?(Required)

Do any operations involve transporting hazardous materials or require a vehicle placard?(Required)

Yes

Do any operations involve work in another state for more than 90 days per year?(Required)

Yes

Any policy or coverage declined, cancelled or non-renewed during the prior 3 years, other than for non-payment of premium?(Required)

Yes

Any vehicle owned or available for regular use but not scheduled on the application?(Required)

Yes

Are any vehicles not solely owned by and registered to the business?(Required)

Yes

Will any covered vehicle be used to transport passengers for hire OR deliver property for compensation or fee, including transportation network companies and on demand delivery services?(Required)

Yes

Has any driver ever been convicted of a criminal offense involving fraud, or any felony during the last 10 years?(Required)

Yes

Does the applicant hire or lease independent truckers (owner-operators) either on a permanent or short-term basis or do any other motor carriers operate under the applicant’s motor carrier authority?(Required)

Yes

Does the applicant ever borrow, hire, rent, or lease a vehicle for business that you do not own?(Required)

Yes

How many drivers are there for all vehicles?(Required)

Please enter a number from 1 to 999.

Any losses for the last four years? If so, when and for how much?

Vehicles

Type	Year	Make	Model	Registered Owner	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Name of the person who referred you (if any)?