For The Business Owner Why are you seeking insurance?New BusinessNo insurance at current businessNeed to change my insuranceLooking to expand my current businessWhat type of business/industry do you have? How many years has the business been operating?*Please enter a number from 0 to 200.Approximate gross annual revenuePlease enter a number greater than or equal to 0.Total number of full time employees?*Please enter a number greater than or equal to 0.Business structure?Sole Proprietor/DBALLCCorporationS CorpUnknown/TBDTotal number of owners?Please enter a number greater than or equal to 1.Do you currently have a buy sell agreement in place?* Yes No N/A For multiple business owners.Is the buy sell agreement fully funded?* Yes No Do you have key person protection in place for key employees? Yes No Do you have an exit or succession plan in place? Yes No What is your top priority?*Protecting my business against the loss of an owner or key employeeBusiness exit or successionBusiness owner retirementRewarding and retaining key peopleProtecting assets against judgement creditorsKeeping income taxes as low as feasibleKeeping estate taxes and costs as low as possibleOtherWhat is your top priority (Other)?Please describe in a sentence or less what your top priority is.Contact InfoCompany Name Your Name First Last Email PhoneMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Country ConsentI4SB shares your information with select third parties for the purpose of matching your expressed insurance needs with the appropriate insurance representative. I4SB is a referring broker with an agreement with New York Life Insurance Company, its affiliated insurance companies (New York Life- NYL), as well as with Berger Briggs Insurance & Risk Solutions, Inc. an ISU Member Agency, all of which authorizes the referring broker, (i4SB) to refer individuals interested in certain life insurance, health insurance, annuities, as well as property & casualty insurance ( collectively, the “products”) NYL’s sole relationship with i4SB is this brokerage agreement and NYL has no other affiliation and neither endorses nor guarantees any services or outside business activities undertaken by Referring Broker, i4SB. Berger Briggs Insurance & Risk Solutions, INC. an ISU Member Agency’s sole relationship with i4SB us this brokerage agreement and Berger Briggs Insurance and Risk Solutions, INC has no other affiliation and neither endorses nor guarantees any service or outside business activities undertaken by referring Broker, I4SB. Referring Broker may receive commissions or other sales based compensation from NYL or Berger Briggs Insurance & Risk Solutions, Inc. for sales of traditional, non-securities, insurance and annuity products to client. Any commissions or other compensation on variable universal life insurance sales will be paid to the Broker-Dealer of the Referring Broker and/or Sub-producer, as applicable by NYLIFE Distributors LLC. Client authorizes the Referring Broker to provide Client’s contact information including name, address and telephone number to NYL and Berger Briggs Insurance and Risk Solutions, INC. so that they may be contacted to discuss various insurance and/or financial products. I agree to the privacy policy.