Commercial New Business Checklist

Complete all required fields. This form will create a lead in both PM and IA AgencyZoom.

Submitting Agent

Loading employees…*

Your email identifies you as the submitting IA agent and will be used for PM lead attribution.

Date

Referred by anyone? *

YesNo

Website

Federal ID #*

Years in Business*

Contact First Name*

Contact Last Name*

Contact Phone*

Business Name*

Business Entity

DBA

NAICS Code

Mailing Address

Street*

Street 2

City*

State *

ZIP*

Physical Address

Street*

Street 2

City*

State *

ZIP*

Physical address same as mailing

Telephone*

Fax

Email Address*

Number of Employees

Annual Revenue / Gross Receipts

Total Annual Payroll

Coverages Needed*

Prior / Current Carrier

Current Policy Expiration

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