CL Intake - Garcia Insurance Services

New Kenner Location: 2400 Veterans Ste 115

Address: 3815 MacArthur Blvd New Orleans, LA 70114
Phone: (504) 875-4077
Email: info@gisnola.com

If you have replaced your roof within the last 5 years please send PAID receipt for installation or a statement from a licensed roofer showing installation date/estimated age of roof to documents@gisnola.com

Commercial Lines Intake Form

Business Details

Business Name:

Business Entity:

FEIN / Tax-ID Number:

Phone Number:

Email:

Mailing Address:

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?

Yes

No

Physical Address:

Street Address City State ZIP Code

Website Address:

Effective Date:

Are You A Contractor?

Yes

No

Brief Description of Operations:

Names and % of Ownership for all Officers:

Full Name

Position

% of Ownership

Year Business Started:

Number of Employees:

Estimated Annual Payroll:

Estimated Annual Revenue:

Additional Contractor Details

Contractors License #

% of work Subcontracted out

% of Residential Work

% of Commercial Work

% of Remodel/Install work

% of New Construction Work

% of Service/Maintenance Work

Do you perform Government/Municipality Work?

Call Email Claims Payments

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