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G

GONZALEZ

AGENCY

Commercial Information Request

*Business Owner First Name

*Business Owner Last name

*Email

*Phone

Preferred contact method

Email

Text

Call

Preferred time to contact

Morning

Lunch

Afternoon

Specified time

*Business Owner Date of Birth

Month

Day

Year

*Business Address

Primary Contact is same as Business Owner

*Business Contact First Name

*Business Contact Last Name

*Business Contact Phone Number

*Business Contact Email

*Business Contact Role

*Residence Address

*Current Insurance?

Yes

No

New Business

*Business Name

*Type of Business/ Industry

*Years in Business

*Years of Experience in Industry

*Business Entity

*Name of Entity

*Business Operations Location

Home

Leased Building

Owned Building

*Coverages Needed

General Liability

Property Coverage

Commercial Auto

Workers Compensation

Commercial Umbrella

Other

*# of Employees (outside of owner)

Additional Information

Get Information!

G GONZALEZ AGENCY

817-281-5505

agent@ggonzalezagency.com

*First Name

*Last Name

*Email

*Phone

Yes, I would like to be contacted for information

Yes, I would like to texted for information

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