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NEW CLIENT INFORMATION
New Client Information Sheet
General Information
Your Name
Your Email address
Coverage to be effective by (date):
Full name of company
Company Type
S-Corp
C-Corp
LLC
Limited Partnership
Sole Proprietor
FEIN#
Address
City
State
Zip
Office Phone
Fax Number
Cell Number
Web Address
Company Operation
Description of operations
Estimated Gross Sales
(Next 12 Months)
Estimated Payroll
(Next 12 Months)
Year Business Started
Number of Employees
Number of Operating Locations
Company Insurance Information
How many claims have you had in the last 3 years?
If you have had claims in the past 3 years, please describe:
Current Insurance Details
Property Coverage
Computers
$
Software
$
Furniture
$
Inventory
$
Other
General Liability Limits
$1,000,000 each occurrence
$2,000,000 General Aggregate
$2,000,000 each occurrence
$4,000,000 General Aggregate
Other
Professional Liability Limits
$1,000,000 each occurrence
$2,000,000 General Aggregate
$2,000,000 each occurrence
$4,000,000 General Aggregate
Other
Deductible Options
$1,000
$2,500
$5,000
$10,000
Other
Worker's Compensation
PA
NJ
DE
Other States:
What Improvements would you like to see in your insurance program going forward?
Submit your Information
We are pleased you have invited VanDyne Insurance to work with you as you manage and protect your business. Those clients we have welcomed to our firm send many of their associates and friends our way because we strive to meet very high standards of excellence. Due to this high volume of new business and so that we can continue to work with all referral efficiently, we may only keep your file open for 30 days after receiving your application.
