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Pierre

124 W Dakota
Pierre SD 57501

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Miller

427 N Broadway
Miller SD 57362

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Businesses

Business Name:(Required)

Address:(Required)

Street Address City State ZIP Code

Phone #:(Required)

Type:(Required)

Corporation

LLC

Individual

Sole Prop

FEIN #:(Required)

Date Business Started:(Required)

Month

Day

Year

Company Owner

Name:

First Last

Nature of Business:

Gross Annual Sales:

Number of Owners:

Number of Employees:

Annual Employee Payroll:

Subcontractors Used:

Annual Cost of Subcontractors:

Square Footage of Location:

Own/Rent:

Own

Rent

Year Building was built:

Updates to Building?:

Additional Information

Prior Insurance:

Length of Coverage (Months and Years):

Number of Additional Insureds Needed:

Any losses in past 5 years? Ask prospect to order 3 year loss history from current company.:

Yes

No

If yes, what kind and amount:

Business Auto/Equipment/Tools:

Year, Make, Model, VIN#, Garaging Location, Cost New, When purchased:

Driver (First)

Name:

First Last

Marital Status:

Married

Unmarried

Sex:

Male

Female

Birth Date:

Month

Day

Year

Social Security #

Drivers License #

Add a Second Driver:

Yes

No

Driver (Second)

Name:

First Last

Marital Status:

Married

Unmarried

Sex:

Male

Female

Birth Date:

Month

Day

Year

Social Security #

Drivers License #

Add a Third Driver:

Yes

No

Driver (Third)

Name:

First Last

Marital Status:

Married

Unmarried

Sex:

Male

Female

Birth Date:

Month

Day

Year

Social Security #

Drivers License #

Add a Fourth Driver:

Yes

No

Driver (Fourth)

Name:

First Last

Marital Status:

Married

Unmarried

Sex:

Male

Female

Birth Date:

Month

Day

Year

Social Security #

Drivers License #

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Section Break

Type of Coverage needed: GL: Aggregate Limit most common $2,000,000

First Choice

Second Choice

Third Choice

Who is Included/Excluded in Work Comp:

What states is work done:

Business Income Amount Needed:



Pierre

124 W Dakota
Pierre SD 57501
605-224-0707



Miller

427 N Broadway
Miller SD 57362
605-853-7774

De Smet Farm Mutual

Pierre Location

124 W Dakota
Pierre SD 57501
605-224-0707

Miller Location

427 N Broadway
Miller SD 57362
605-853-7774

De Smet Farm Mutual

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