How can we help you? Step 1 of 4 - Intro 25% Please answer all the questions on this form. We look forward to providing as much value as possible and protecting the things that are important to you. Once received, I'll get started right away working on your quotes. By filling out this form, you give us permission to communicate with your via text, email, and phone call. You may also see our privacy policy here: https://www.insuranceeptx.com/privacy/ Are you a current client of our Agency?(Required)No, I'm a new clientYes, I'm a current clientWhat are you looking for help with? Check all that apply:(Required)If you want us to provide a top to bottom review of your business insurance needs, please select "Everything." Everything Business Owner Package Policy General Liability Commercial Auto Commercial Property Workers Compensation Commercial Auto Commercial Umbrella Bonds, Equipment, Other, Etc. What effective date do you want for your new insurance program?(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your main reason for reaching out to us now?I am shopping my upcoming policy renewalI hear you guys are awesome!Unhappy with my current agent/brokerUnhappy with a recent claim experienceJust curious what TWFG-DIS can do for me Your Name(Required) First Last What is the legal name of your business entity?(Required)Is your DBA name different from your legal entity name?NoYesYour DBA (Doing Business As) nameBusiness Type Corporation LLC Sole Prop What year was the business Established?Your Federal EIN / Tax I.D. Number (if you have one)(XX-XXXXXXX)Your Preferred Phone Number(Required)Your Preferred Email(Required) Your mailing/correspondence address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code If there is a building to be insured that is not the above address please give us that address below Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Briefly describe your business operations:(Required)PLEASE NOTE: If you selected Commercial Auto Quote please list DRIVERS and VEHICLES here or upload a file with a list of those here on this form please!What is your projected gross revenue for the upcoming 12 months?(Required)How many employees does your business have?01-23-1011-50More than 50 employeesWhat is your projected total payroll for the upcoming 12 months?(Required)How much square feet of space does your business lease or occupy?(Required)If property coverage is requested, please let us know the dollar amount of coverage needed for your BUSINESS PERSONAL PROPERTY (furniture, equipment, inventory, walls in coverage [for commercial condominiums])Does your business own or lease your space?LeaseOwnDoes your business OWN or LEASE any automobiles or mobile equipment?No, we don't OWN or LEASE vehicles or mobile equipmentYes, we OWN vehicles or mobile equipmentYes, we LEASE vehicles or mobile equipmentYes, we both OWN and LEASE vehicles or mobile equipment How did you find out about TWFG - DelaFuente Insurance Services? Personal Referral Google Search Facebook group/post Instagram Word of mouth Who referred you to us?(Required)What should we know now so we can deliver an outstanding experience for you?You may upload files hereIt is extremely helpful for this process if you're able to share current policy documents with us at the beginning. Since we are an independent brokerage, our loyalty is to you, and not any particular company. Drop files here or Select files Max. file size: 5 MB, Max. files: 5. Communication Consent(Required)TWFG - DIS is committed to respecting our current and future clients' privacy and communication preferences. So that we may remain compliant with state and federal regulations, we need your expressed permission to communicate with you using phone, text and email as needed. You may opt-out of all future communication at any time by making your preferences known to us. TWFG - DIS operates by the simple rule of "treat other people the way you want to be treated." TWFG - DIS Privacy Policy: https://www.insuranceeptx.com/privacy/ I authorize TWFG - DIS to communicate with me using the information provided on this form for the purpose of assisting with my insurance program.
