Life and Annuities – Insure with BiZ

Complete the form below and select the type of insurance you need. The form will show only the questions that apply.

Contact Information

First Name *

Last Name *

Email Address *

Phone Number *

Mailing Address *

City *

State *

ZIP Code *

Preferred Contact Method *

Insurance Type

What type of insurance do you need help with? *

Commercial / Business Insurance

Business Name * Business Address What type of business do you need a quote for? Specific type of business

Please describe your business type

Coverage Requested

Select all that apply. Options update based on the business type.

Other coverage needed

Business Size & Details

Years in Business

Business Structure

Full-Time Employees

Part-Time Employees

1099 / Subcontract Workers

Estimated Annual Gross Receipts

Estimated Annual Payroll

Business Location Type

Number of Business Locations

Approximate Business Square Footage

Briefly describe what your business does

Construction / Builders Risk Details

Number of Field Workers

Largest Job Value

Residential, Commercial, or Both?

Are you licensed?

Describe the type of work performed

Commercial Auto Details

Number of Business Vehicles

Number of Drivers

Vehicle Use

Operating Radius

Transportation / Trucking Details

DOT Number

MC Number

Number of Vehicles

Number of Trailers

Number of Drivers

Operating Radius

Type of cargo transported

Dealer / Car Repair Details

Business Type

Number of Repair Bays

Vehicles Stored Overnight?

Vehicle Inventory Value

Food Industry / Hospitality Details

Business Type

Seating Capacity

Do you sell alcohol?

Estimated % of Sales from Alcohol

Real Estate Details

Property Type

Number of Units

Year Built

Square Footage

Surety Bond Details

Bond Type

Bond Amount

Vacant Building Details

Vacant Building Address

Reason for Vacancy

How long has it been vacant?

Are utilities on?

Personal Insurance

Select all that apply.

Car Insurance Home Insurance Condo Insurance Renters Insurance Rental Dwelling Insurance Motorcycle / Off-Road / Boat

Car Insurance Details

How many vehicles need to be insured?

Number of Drivers

Garaging Address

Garaging ZIP Code

Vehicle 1

Year

Make

Model

VIN

State Registered In

Vehicle Ownership

Lienholder / Leasing Company

Primary Driver

Vehicle Use

Estimated Annual Mileage

Coverage Desired

Vehicle 2

Year

Make

Model

VIN

State Registered In

Primary Driver

Vehicle 3

Year

Make

Model

VIN

State Registered In

Primary Driver

Vehicle 4

Year

Make

Model

VIN

State Registered In

Primary Driver

Upload vehicle lists or registration documents for 5+ vehicles

You may select multiple files, including vehicle schedules, registration documents, or spreadsheets.

Additional vehicle notes

Driver Information

Driver 1 Name

Driver 1 Date of Birth

Driver 2 Name

Driver 2 Date of Birth

Any accidents, tickets, claims, or violations in the past 5 years?

Home Insurance Details

Property Address

Year Built

Approximate Square Footage

Roof Age

Construction Type

Additional home details

Condo Insurance Details

Condo Address

Approximate Square Footage

Unit Floor

Estimated Personal Property Value

HOA Master Policy Type

Renters Insurance Details

Rental Address

Estimated Personal Property Value

Desired Liability Limit

Do you have pets?

Do you have roommates?

Rental Dwelling Insurance Details

Rental Property Address

Property Type

Number of Units

Year Built

Estimated Monthly Rent

Motorcycle / Off-Road / Boat Details

Type

Year

Make

Model

VIN / HIN

Estimated Value

Life / IRA / Annuities

Who is this for?

For Businesses

Annuities Buy-Sell Agreement Cash Value / Savings Maximizer IRA LTC Long-Term Care Rider Keisen / Whole Life Insurance Buster Key Employee Living Benefits Solo 401k Term Life Whole Life Universal Life

Business Name Briefly describe the business need

For Individuals

Annuities Burial Costs Cash Value / Savings Maximizer Dependent Life Insurance IRA LTC Long-Term Care Rider Keisen / Whole Life Insurance Buster Living Benefits Term Life Transitional Life Whole Life Universal Life

Applicant Details

Date of Birth

Height

Weight

Tobacco / Nicotine Use

Additional life / IRA / annuities notes

Not Sure

Tell us what you need help with

Current Insurance & Claims

Do you currently have insurance?

Current Insurance Carrier

Policy Expiration Date

Upload current declaration pages, policies, or related documents

You may select more than one file. Accepted files: PDF, JPG, PNG, DOC, and DOCX.

Any claims in the past 5 years?

Please briefly explain the claim history

Additional Documents

Do you have additional documents to upload?

Upload one or more additional documents

You may select multiple policies, declaration pages, vehicle lists, contracts, photographs, spreadsheets, or other related documents.

How Did You Hear About Us?

How did you hear about us?

Please tell us how you heard about us

Additional Information

Anything else we should know?

This form is for intake purposes only and does not bind coverage, guarantee approval, or replace a formal insurance application.