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Commercial Intake Form
Personal Intake Form

First Name*

Last Name*

Phone Number*

Address*

City*

State/Region*

Postal Code*

Contact Email*

How did you hear about us?*

Referred by:

What type of Commercial Insurance do you need?* Please select one
D&O / Management LiabilityCommercial Auto InsuranceBusiness Liability Insurance (General, Professional, BOP, Workers' Comp and etc.)Event Policy

Directors & Officers

1. In the last 12 months, has the company defaulted on any debt covenants and/or are there any such defaults planned or anticipated in the future?*
YesNo

If "YES", please provide the details

2. Does the company have any debt (i.e. lines of credit, convertible debt)?*
YesNo

If "YES", please provide the details

3. Has the company (organization or person) been subject to, or involved in any of the following over the past five years or does the company anticipate in the future?* An antitrust, copyright, patent litigation or other intellectual property litigation (including but not limited to copyright, patent, trademark, trade secret, service mark, or trade name)? A civil, criminal, or administrative proceeding?
YesNo

If "YES", please provide the details

4. Is the SEC or IRS presently investigating or requesting information from the company or any director or officer of the company?*
YesNo

If "YES", please provide the details

5. Is the company involved in any related party transactions as defined within generally accepted accounting standards?*
YesNo

If "YES", please provide the details

6. Is this insured a Community Association? If so, please answer the following:*
YesNo

If "YES", please provide the details

Coverage Selection

1. Are you interested in Directors & Officers coverage?*
YesNo

Who is your current Directors & Officers carrier?

Limit

Retention

Continuity date

2. Are you interested in Employment Practice Liability (EPL) coverage?*
YesNo

Who is your current Employment Practice Liability (EPL) carrier?

Limit

Retention

Continuity date

3. Are you interested in Fiduciary Liability?*
YesNo

Who is your current Fiduciary Liability carrier?

Limit

Retention

Continuity date

4. Are you interested in Cyber?*
YesNo

Who is your current Cyber carrier?

Limit

Retention

Continuity date

5. Are you interested in Tech Errors & Omissions?*
YesNo

Who is your current Tech Errors & Omissions carrier?

Limit

Retention

Continuity date

Financials & Ownership

1. Financial Details

1. Upload latest fiscal year income statement

2. Upload last quarter balance sheet

Total company revenue as of the last fiscal year*

Total company assets as of last month*

Total cash in company's bank account(s) as of last month*

Total company liabilities as of last month*

Net income (or net loss) of company as of last fiscal year*

What is the company’s average monthly burn rate?*

Does the company have positive equity currently?*
YesNo

2. Ownership Details

1. Upload cap table

2. Upload a list of board members and officers of the company

Warranty: Prior Knowledge of Fact or Circumstance / Situation?

Does the Applicant or any person or entity proposed for coverage have any knowledge of or information about any fact, circumstances, situation, transaction, event, incident, act, error, omission, misstatement, misleading statement, neglect, breach of duty or other matter which could reasonably be foreseen to give rise to a claim or loss that may fall within the scope of proposed insurance:

Please select:*
YesNo

If "YES", please provide the details

Kindly attach your current policy documents or any documents that will help us write this policy.

Any other important details that will help us write this policy?*

Confirmation* I confirm that all information provided is correct.

Commercial Auto Insurance

Driver 1 - Full Name*

Driver 1 - Date of Birth*

Driver 1 - Gender*
MaleFemale

Driver 1 - Driver's License Number*

Driver 1 - Driver's State/County of License*

Driver 2 - Full Name

Driver 2 - Date of Birth

Driver 2 - Gender
MaleFemale

Driver 2 - Driver's License Number

Driver 2 - Driver's State/County of License

Driver 3 - Full Name

Driver 3 - Date of Birth

Driver 3 - Gender
MaleFemale

Driver 3 - Driver's License Number

Driver 3 - Driver's State/County of License

Vehicle Details

Vehicle 1 - Year, Make & Model*

Vehicle 1 - VIN*

Vehicle 1 - Vehicle Use*
(Please select both if applicable)
CommercialPersonal

Vehicle 1 - Furthest Distance Vehicle Is Driven:*
200 miles or less300 miles400 miles500+ miles

Vehicle 1 - Is this a Trailer?*
YesNo

Vehicle 1 - Garaging Location*

Vehicle 2 - Year, Make & Model

Vehicle 2 - VIN

Vehicle 2 - Vehicle Use
(Please select both if applicable)
CommercialPersonal

Vehicle 2 - Furthest Distance Vehicle Is Driven:
200 miles or less300 miles400 miles500+ miles

Vehicle 2 - Is this a Trailer?
YesNo

Vehicle 2 - Garaging Location

If You Have More Than 2 Vehicles, Enter the Full Details for The Rest
or send the list of your entire Vehicles to sales@patiencenoahins.com

What is your DOT Number? (If applicable)

Coverage Detail

Liability Limits
$1 Million$500K$300K$100K

Current Commercial Auto Policy

Do you have any current Commercial Auto Insurance?*
YesNo

Commercial Auto Insurance Current Policy

Commercial Auto Insurance Current Policy Expiry Date

Any other important details that will help us write this policy?*

Confirmation* I confirm that all information provided is correct.

Business Liability Insurance

Number of employees*

Business Liability Insurance Estimated Annual Revenue*

Business Liability Insurance Estimated Annual Payroll*

Coverage Interest*
*Select all that apply General LiabilityProfessional LiabilityWorkers CompCommercial PropertySurety BondMotor CargoBOP (General Liability & Property)Other

If You Chose Others, Please Explain:

Kindly attach your current policy documents or any documents that will help us write this policy.

Any other important details that will help us write this policy?*

Confirmation* I confirm that all information provided is correct.

Special Event

Location of Event

What is the applicant's role in the event? HostVendorSponsorOrganizerBartenderCatererCatering ServicePerformer/Entertainer

Start date of event

End date of event

Which Lines of Business to Quote?
Select all that apply General LiabilityLiquor Liability

Event Description*

Number of attendees per day

Will any product samples be distributed to attendees? YesNo

Will the event end by 2 AM? YesNo

Will professional bartenders (or formal alcohol awareness trained servers) be used for the service of alcohol? YesNo

Does the event include any medical treatment or health screenings? YesNo

Will overnight camping or dormitory accommodation occur at the event? YesNo

Kindly attach your current policy documents or any documents that will help us write this policy.

Any other important details that will help us write this policy?*

Confirmation* I confirm that all information provided is correct.

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Get Started with your Policy

Let's get to know you.

First Name*

Last Name*

Phone Number*

Date Of Birth*

Address*

City*

State/Region*

Postal Code*

Contact Email*

Personal Insurance Home InsurancePersonal Auto Insurance

How did you hear about us?*

Referred by:

Personal Home Insurance

Current Policy Information

Insured Full Name (If different from Primary Contact)*

Full Property Address*

Mailing Address (If different from Property Address)

Home Insurance Current Insurance Company

Current Expiration Date*

What is the closing date?*

Is this a new purchase? YesNo

Is this being rented to other people? YesNo

Property Details

When was the property built?

Year Heat was updated

Year Roof was updated

Year Plumbing was updated

Kindly attach your appraisal documents / current policy documents / any documents that will help us write this policy.

Any other important details that will help us write this policy?

Confirmation* I confirm that all information provided is correct.*

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Personal Auto Insurance

Automobile Information

Vehicle no. 1 - VIN*

Vehicle 1 - Is this newly purchased? YesNo

Is this a motorcycle? YesNo

Is this a trailer? YesNo

Vehicle no. 2 - VIN

Vehicle 2 - Is this newly purchased? YesNo

Is this a motorcycle? YesNo

Is this a trailer? YesNo

Vehicle no. 3 - VIN

Vehicle 3 - Is this newly purchased? YesNo

Is this a motorcycle? YesNo

Is this a trailer? YesNo

Driver Information

Driver 1 - Full Name*

Driver 1 - License Number*

Driver 1 - Date of Birth*

Driver 1 - License State*

Driver 2 - Full Name

Driver 2 - License Number / State

Driver 2 - Date of Birth

Driver 2 - License State

Driver 3 - Full Name

Driver 3 - License Number / State

Driver 3 - Date of Birth

Driver 3 - License State

Coverage Information

Current Carrier

Expiration Date

Kindly attach your current policy documents / registry documents / title of vehicle / any documents that will help us write this policy.

Any other important details that will help us write this policy?

Confirmation* I confirm that all information provided is correct.*

Previous Next

I agree to receive other communications from Patience Noah Insurance.

By clicking submit below, you consent to allow Patience Noah Insurance to store and process the personal information submitted above to provide you the content requested.