CL Intake | Clear View Insurance Specialists

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Office Phone

(816) 232-7400

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Email Address

admin@clearviewinsure.com

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Corporate Address

3849 Frederick Ave
Saint Joseph, MO 64506

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Disclaimer: State of California DOI doing business as name – MO Clear View Insurance Agency

Clear View CL Intake

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Business Details

Business Name:*

*Please list your entity name or personal name if you are a sole proprietor. *PLEASE ADD LLC or INC at the end of business name based on the entity type.

Business Website:

Business Entity

FEIN / Tax-ID Number or Social Security Number

Business Phone Number:*

Business Contact Email:*

Primary Contact Name

First Last

Primary Contact Phone Number:*

Primary Contact Email:*

Names and % of Ownership for all Officers:

Full Name

Position

% of Ownership

Owners DOB*

Mailing Address:*

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?

Yes

No

Location Address:

Street Address City State ZIP Code

Years of Experience

Requested Effective Date:

Year Business Started:

Coverage(s) Needed

Business Auto

Building/Property

Cyber Liability

General Liability

Workers Comp

Inland Marine

Are You A Contractor?

Yes

No

Do you use multi-factor authentication?

Yes

No

Do you currently carry cyber liability?

Yes

No

Current Cyber Carrier

Number of Full-Time Employees:

Number of Part-Time Employees:

General Liability Limits Requested

Gross Revenue

Owners can exclude themselves from coverage.

Yes

No

Estimated Total Payroll:

(not including any owners payroll)

Please provide a detailed description of business operations:*

Please list ALL operations of the company.

Additional Contractor Details

Contractors License #

% of work Subcontracted out

% of Residential Work

% of Commercial Work

% of Remodel/Install work

% of New Construction Work

% of Service/Maintenance Work

Do you perform Government/Municipality Work?

Business Auto Information

How many vehicles are owned by the business?

How many trailers are owned by the business?

How many drivers work for the business?

Current Carrier:

Current Payment Plan:

Vehicle #1

Year*

Make*

Model*

Vehicle #1 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #2

Year*

Make*

Model*

Vehicle #2 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #3

Year*

Make*

Model*

Vehicle #3 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #4

Year*

Make*

Model*

Vehicle #4 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #5

Year*

Make*

Model*

Vehicle #5 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #6

Year*

Make*

Model*

Vehicle #6 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #7

Year*

Make*

Model*

Vehicle #7 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #8

Year*

Make*

Model*

Vehicle #8 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #9

Year*

Make*

Model*

Vehicle #9 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #10

Year*

Make*

Model*

Vehicle #10 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Trailer #1

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #1 VIN

Trailer #2

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #2 VIN

Trailer #3

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #3 VIN

Trailer #4

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #4 VIN

Trailer #5

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #5 VIN

Trailer #6

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #6 VIN

Trailer #7

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #7 VIN

Trailer #8

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #8 VIN

Trailer #9

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #9 VIN

Trailer #10

Year

Make

Model

Trailer Value*

Length

Is trailer enclosed?

Yes

No

Trailer #10 VIN

Driver #1

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #2

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #3

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #4

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #5

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #6

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #7

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #8

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #9

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #10

Name

First Last

DL#

Date of Birth

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Please Upload any additional Drivers

Max. file size: 1 GB.

Please Upload any additional Vehicles

Max. file size: 1 GB.

Please Upload any additional Trailers

Max. file size: 1 GB.

Building/Property

Current Carrier

Interest in Building:

Owner

Tenant

% of building occupied:

% leased to others:

Year Built

Foundation Type:

Slab

Crawl Space

Basement

Building type:

Frame

Masonry

If frame what type of siding?

Wood

Vinyl

Stories:

1

2

3

4

5

6

7

8

9

10

Total Square Feet:

Roof Age:

Roof Type

Shingles

Wood Shingles

Metal

Clay Tiles

Flat Roof

Age of Wiring:

Plumbing:

Heating:

Sprinkler System:

Yes

No

Need Sign Coverage:

Yes

No

Amount of Coverage

Is there a Premises Alarm Active?

Yes

No

Value of Personal Contents:

Coverage Limit for Building:

Coverage Requested

(Actual Cash Value Claim payout is depreciated based on age of property)

Number of Buildings

Inland Marine

Tools/Equipment coverage needed?

Amount of Coverage Needed

List

Item Description

Value

Assigned Advisor

Who Filled Out The Intake***

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Products

Auto Insurance
Boat Insurance
Commercial / Business Insurance
Health Plans and Insurance
Homeowners Insurance
Life Insurance
Motorcycle Insurance
Personal Insurance
Recreational Vehicles
Renters Insurance
Umbrella Insurance
Workers Compensation

24/7 Access

File a Claim
Policy Change Request
Certificate of Insurance
Replacement Auto ID
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Let’s Talk!

Tel: (816) 232-7400
Fax: (816) 259-5047
Email: admin@clearviewinsure.com

3849 Frederick Ave
Saint Joseph, MO 64506

© 2015-2026, Supersurance, Inc dba Clear View Insurance Specialists. All Rights Reserved. License # MO 8134886

Disclaimer: State of California DOI doing business as name – MO Clear View Insurance Agency