| Keystone Insurance Group | Form KIG-210 Rev. 06/26 |
Commercial Insurance ApplicationComplete all applicable sections. Print clearly. | |
| Section 1 - Requesting Party | |||
| Legal name | Jordan Lee | jordan@northstarbakery.com | |
| Applicant | Northstar Bakery LLC | ||
| File ref. | KIG-26-0907 | Received | 06 / 03 / 2026 |
| Section 2 - Coverage Requested | ||
| 1 | General liability | |
| 2 | Commercial property | |
| 3 | Workers' compensation | |
| 4 | Commercial auto | |
| Section 3 - Applicant Signature | ||
Applicant signature | 06 / 03 / 2026 Date | Authorized |
Official Use Only - Do Not Fill Internal processing and review fields | |||||
| Intake clerk | Queue code | Reviewer | Approved Yes No | Archive box | Scan ID |
| Internal comments | Follow-up required NoneCallEmail | Disposition notes / retention schedule | |||