Fallaize Insurance Agency — New Business Intake

Let's get your policy started

This should take about 5 minutes. We'll ask you to photograph your driver's license, then fill in a few details about you or your business. Nothing here is submitted to your insurance carrier — it just gets your information ready for your agent.

Tip: this works best on your phone, so you can use your camera directly for the license photos.

Driver's License — Front

Take a clear photo of the front of your driver's license. Make sure all text is in focus and readable.

📇

Tap to take a photo or upload one

Please add a photo of the front of your license to continue.

Driver's License — Back

Now flip it over and photograph the back.

📇

Tap to take a photo or upload one

Please add a photo of the back of your license to continue.

Customer Information

Tell us about you or your business.

Customer Name(s)*

DBA (if applicable)

Business Entity

Federal EIN (optional)

Business Classification (what does the business do?)

Year Business Started

Years of Mgmt. Experience

Number of Employees

Annual Revenue $

Total Payroll $

Contact Details

How should we reach you?

Phone Number*

Email*

Secondary Phone (optional)

Secondary Email (optional)

If someone other than you is the main point of contact:

Contact First Name

Contact Middle

Contact Last Name

Address

Street Address*

City*

State*

Postal Code*

Country

Web Site (optional)

Property & Coverage Info

Only fill in what applies to you — skip anything that doesn't.

BPP Property Limit $ (business personal property)

Building Limit $

Rated Revenue $

Rated Payroll $

Review & Submit

Check everything below before submitting.

✅

Thanks — you're all set!

Your information has been prepared. Choose how you'd like to send it to us: