Employees and Benefits Questions 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.Approximate annual payrollPlease 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/TBDDo you have key person protection in place for key employees? Yes No Do you have any of the following in place: Non-qualified deferred compensation plan, Executive bonus plan, split dollar arrangement? Yes No What is your top priority?*Benefits for my employeesObtaining required insuranceProtecting my business against the loss of a key employeeBusiness successionRewarding and retaining key peopleOtherWhat 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* Enter Email Confirm Email PhoneMailing Address Street Address Address Line 2 City 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 State ZIP Code Consent*I4SB 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.