Commercial General Liability Quote

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Name
Business Name
What is business entity
Street Address
City_and_State
Phone Number
Alternate Telephone
Fax Number
Email Address
Location 1 Detail Information
How many full time employees?
How many part time employees?
Location 2 Detail Information
Street Address
City and State
How many full time employees?
How many part time employees?
Location 3 Detail Information
Street Address
City and Zip
How many full time employees?
How many part time employees?
How many seasonal employees?
Underwriting Information
Describe is the nature of your business?
Number of owners or officers
Annual owners/officers salary
Annual employees salaries
Total annual gross receipts
Years in business
Is this business open 24 hours a day
Are you aware of any claim situation not filed?
Has there been a company merger within the last 24 months?
Claims Information
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company
How much are you paying now?
What is the liability limit requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.
Or Specify Other:

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