Jackson Hewitt Insurance Program

Business Name(Required)

FEIN(Required)

Primary Contact Name(Required)

First Last

Primary Phone Number(Required)

Primary Contact Email(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Current Carrier(Required)

Have you had any claims in the last three (3) years?(Required)

Please select line(s) of coverage needed:(Required)

If requesting Cyber or Professional Liability coverage, a supplemental application will be required for proposal. Application(s) will be sent upon completion of intake form.

General Liability

Property

Auto

Workers Compensation

Cyber Liability

Professional Liability (E&O)

Umbrella

How many locations do you have?(Required)

Do you own any of the buildings?(Required)

Location(s)(Required)

Street Address

City

State

Walmart location

Occupied square feet

Projected annual gross revenue

Projected annual payroll

Contents coverage limit requested

Click the + to add more locations

If more than 5 locations to add, a supplemental location schedule will be required to complete(Required)

I have more than 5 locations, send me a location schedule

I have entered all my locations above

Auto(s)(Required)

Year

Make

Model

VIN

Click the + to add more locations

Driver(s)(Required)

First name

Last name

Date of birth

Drivers license #

State

Click the + to add more locations