Business Insurance Application | Shine Insurance Agency

First Name*

First Last

Email*

Enter Email Confirm Email

Phone*

(###)###-####

Business Name*

What industry best describes your business?*

Commercial Real Estate

Trucking - Transportation

Technology

All Others

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Website

Describe your business*

In what state is your business registered?*

How many years have you been in business?

Just Starting

1-2 Years

3-5 Years

6 Years +

How many employees do you have?

0

1-5

6+

What is your total payroll?*

What is your projected annual revenue for the next year?*

What is your FEIN?

If you don't know, simply skip this question.

What is your USDOT#?*

What is your MC#?*

Have there been any claims in the last 5 years?*

Yes

No

Please describe the claims*

Please attach your current policies

Max. file size: 50 MB.

Please attach the last four quarters IFTA's:

Max. file size: 50 MB.

Please attach complete list of trucks/power units

Max. file size: 50 MB.

Please attach complete list of trailers

Max. file size: 50 MB.

Please attach complete list of drivers

Max. file size: 50 MB.

Please attach any additional supporting documents

Max. file size: 50 MB.

Are they any specific concerns or coverages you'd like to address?

Name

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