Client Information
First Name
Last Name
Company
Job Title
Phone Number
✓ Valid
Email
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Address, City, State, Zip
Website
Industry
Legal Structure
Sole Prop
LLC
C Corp
S Corp
Business Profile Section
Offer Employee Health Insurance?
Custom design your solution over a shelf-based solution?
Experiment/test new materials, supplies or chemicals?
Perform any design work?
Have any other locations out of City or State?
Export product to other countries?
Have a wholesale component to your business?
Perform any training for yourself or your team via the internet?
Operate as a franchise?
Have received Employee Retention Tax Credits?
Did your company receive a PPP loan?
Experience a 50% drop in revenue for any quarter in 2020 versus 2019 due to the pandemic?
Experience a 20% drop in revenue for any quarter in 2021 versus 2019 due to the pandemic?
Was your company forced to close due to any government mandates?
Did your company experience significant supply chain or operational disruption due to the pandemic?
Improved or upgraded your website?
Initiated any type of social media campaigns?
Changed, adjusted or improved your eCommerce software?
Made adjustments to (or create a new) business model, process or formula/product?
Changed your procedures/processes?
Had any risk with your business?
How much has the business paid in taxes over the past 3 years?
0-49k Non-Q
50-100k
101-200k
201-500k
501-1m
1m+
Are you in need of a business loan? If so, how much?
Not at this time
5 to 49k
50-100k
101-200k
201-500k
501-1m
1m to 5M
5M +
How many new employees (including replacements) do you hire per year?
Do you own any commercial property?
Yes
No
Was the property Purchased or Built?
Purchased
Built
Year of Acquisition
Total Construction/Purchase Cost
Total Renovation Cost Including Green upgrades to Roof / Windows / Lighting
Annual Property taxes
Medical Only: Unpaid patient insurance claims greater than 90 days
Do you take Credit Cards?
Yes
No
Estimated Annual Amount Processed?
Annual Payroll Management Expense?
Annual Healthcare Expense?
Annual Workers Comp premium?
Monthly Natural Gas Expense?
Monthly Electric Expense?
Monthly Shipping Expense?
Number of total employees?
How many W2 employees?
How many W9 (1099) contractors?
Number of Principals
Average Annual Income/Wage/Salary per Principal
Number of Management
Average Annual Income/Wage/Salary per Manager
Number of General Employees
Average Annual Income/Wage/Salary per General Employee
Agent Name
Company
Phone Number
✓ Valid
Email
Co-Agent
Affiliate
Benefit Summary Section
Natural Gas Cost Reduction
Electric Cost Reduction
Payroll Cost Reduction
Healthcare Cost Reduction
Shipping Cost Reduction
Hiring Tax Incentive
Workers Comp Premium Reduction
Credit Card Fee Reduction
Commercial Property Owners Incentive
Estimated Insurance Claim Recovery
Activity Specific Rebates and Incentives
Projected Benefit Totals
Company Benefit
Direct to Employee Benefit
Total Organizational Benefit
Schedule Appointment
Schedule Appointment