Business Insurance Request Complete the below request form and our team will be in touch ASAP. "*" indicates required fields Are you a current RiskWell Client?*No, I will be a new clientYes, I'm a current clientYour Name* First Last What is the legal name of your business entity?*Is your DBA name different from your legal entity name?NoYesYour DBA (Doing Business As) nameYour Federal EIN / Tax I.D. Number (if you have one)Format: XX-XXXXXXXYour Preferred Phone Number*Your Preferred Email* Your mailing/correspondence address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What are you looking for help with? Check all that apply:*If you want us to provide a top to bottom review of your business insurance needs, please select "Everything." Everything Business Owner Package Policy General Liability Commercial Property Workers Compensation Commercial Auto Commercial Umbrella Bonds, Equipment, Other, Etc. What effective date do you want for your new insurance program?* Month Day Year What is your main reason for reaching out to us now?I am shopping my upcoming policy renewalI hear you guys are awesome!Unhappy with my current agent/brokerUnhappy with a recent claim experienceJust curious what RiskWell can do for meLocation InfoIs your location address different from your mailing address?*No, they are the sameYes, my location and mailing addresses are differentLocation Address Needing Coverage Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Briefly describe your business operations:*What is your projected gross revenue for the upcoming 12 months?*How many employees does your business have?01-45-1011-50More than 50 employeesWhat is your projected total payroll for the upcoming 12 months?*Does your business own or lease your physical location?LeaseOwnDoes your business OWN or LEASE any automobiles or mobile equipment?No, we don't OWN or LEASE vehicles or mobile equipmentYes, we OWN vehicles or mobile equipmentYes, we LEASE vehicles or mobile equipmentYes, we both OWN and LEASE vehicles or mobile equipmentWrap UpHow did you find out about RiskWell? Personal Referral Google Search McKinney Chamber of Commerce Local event Facebook group/post YouTube video Word of mouth Who referred you to us?*Please share any remaining info/details that will help us deliver you a great experienceYou may upload files hereIt is extremely helpful for this process if you're able to share current policy documents with us at the beginning. Since we are an independent brokerage, our loyalty is to you, and not any particular company. Drop files here or Select files Max. file size: 98 MB, Max. files: 5. Communication Consent*RiskWell is committed to respecting our current and future clients' privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you using phone, text, email and ringless voicemail as needed. This consent has no time restriction and is offered in perpetuity. You may opt-out of all future communication at any time by making your preferences known to us. RiskWell operates by the simple rule of "treat other people the way you want to be treated." I authorize RiskWell to communicate with me using the information provided on this form for the purpose of assisting with my insurance program..
