General Liability Insurance

Name of Company

Contact Person

First     Last  

Contact Number (with area code)

Fax Number (with area code)

Address

Street  

Suite Number  

City     St  TEXAS ALABAMA ALASKA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IDAHO IOWA ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MISSOURI MINNESOTA MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NEVADA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING   Zip 

Email Address *

Web Address

Who Referred You To Our Site?

Please Select One Agent Search Engine Yellow Pages Other

If you selected Agent or Other, please indicate who

If you selected Search Engine, please indicate which one

Nature of Business (please provide a detailed description)

Federal Employer ID#

Years in Business

Please Select One 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50+

Insurance History

Present Insurance Company

Loss History

General Liability

Gross Sales

W2 Payroll

1099 Payroll

Do You Use Subcontractors?

Yes         No

If Yes, Annual Payroll

Do they carry General Liability?

Yes         No

Are Your Subcontractors Insured?

Yes         No

Property

(Many of the most competitive programs include property coverage so please complete the following)

Is Building Coverage Required?

Yes         No

If Yes, Amount

Building Address

Square Footage of Building

Number of Stories

Year Built

If built before 1985, indicate year when wiring, roof, plumbing were updated  

Construction (Exterior Facade)

Building Value

$ 

Business Personal Property

$  Include all inventory, furniture & tenant finish out.

Do you have an Alarm System?

Yes         No

Do you use a Monitoring Company?

Yes         No

If Yes, which?

Is Building Sprinklered?

Yes         No

Additional Questions or Comments