Page 1 of 6

Shay Koko — Commercial Insurance Intake

SHAY KOKO INSURANCE AGENCY
Insurance With Intent. Service With Soul.

Tell us about your business so Shay can review your insurance needs and determine the information needed to obtain coverage options. Please do not enter Social Security numbers, payment information, or other sensitive financial credentials in this form.

Business & Contact Information

Legal Business Name

DBA / Trade Name

Primary Contact Name

Email

Phone

Business Website

Business Address

City, State ZIP

Business Structure

Year Business Started