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General Liability
Please note that this form is for a
REQUEST ONLY
. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time,
ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE
, and call our office.
I understand that filling out and submitting this form
DOES NOT
bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.
General Info
Name:
Address:
City:
State:
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
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Massachusetts
Maryland
Maine
Michigan
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Missouri
Mississippi
Montana
North Carolina
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New Hampshire
New Jersey
New Mexico
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip Code:
Phone:
Cell/Alternate Phone:
Email Address:
Best Time To Contact:
8:00 am
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
Contact By:
Home Phone
Cell Phone
Email
Business Information
Business Name:
Years Experience:
Year Business Started:
Entity Type:
Chapter S Corp
Corporation
Individual
Joint Venture
Limited Liability Company
Not for Profit
Partnership
Describe Nature of Business:
General Liability
Please provide us the desired limits you are looking for. If you do not know we will call you:
Liability:
None
Please Call
100,000.00 single limit
100/300
250/500
500/1,million
1 million/2 million
300,000 single limit
500,000 single limit
1,000,000 single limit
Professional Liability
None
Please Call
100,000
300,000
500,000
1,000,000
5,000,000
Products/Completed Opps Liability:
None
Please Call
100,000
300,000
500,000
1,000,000
5,000,000
Property Rented:
None
Please Call
50,000
Medical Expenses:
None
Please Call
5,000
10,000
Deductible:
Please Call
250
500
1000
Payroll:
Sales:
Premise Information
Street:
City:
County:
Zip Code
City Limits
Inside
Outside
Ownership Interest:
Own
Rent
Year Built:
Square Footage:
Part Occupied:
Construction Type:
CBS
Frame
Joisted Masonry
Brick Over Frame
Superior Form
Other
Roof Type:
Shingle
Clay Tile
Other
Monitored Alarm:
Yes
No
Additional Locations:
Enter the information requested above for any additional locations below:
Rating Information
Are you a subsidiary of another entity?:
No
Yes
Do you have a formal safety program?:
No
Yes
Any Exposures to Flammables, Explosives, Chemicals?:
No
Yes
Any Catastrophic Exposures?:
No
Yes
Any policy or coverage declined, cancelled or non-renewed in the past 3 years?:
No
Yes
Any past losses due to sexual abuse or molestation allegations, discrimination, negligent hiring?:
No
Yes
During the past 10 years, has any applicant been convicted of any degree of the crime of arson?:
No
Yes
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?:
No
Yes
Remarks for Questions Above
If you answered yes to any of the above, please explain in the box below.
Additional Information
In the box below, please provide any additional information you feel may be necessary for us to provide you with the best quote possible such as additional operators, coverages engines, etc.
Enter text above EXACTLY as it appears:
Serving the Treasure Coast for over 20 Years
Request a Quote:
Package Policy
General Liability
Personal Auto
Personal Homeowners
Commercial Auto
Umbrella
Inland Marine
Professional Liability
Workman's Compensation
Boiler & Machinery
Aircraft Liability
Commercial Flood
Commercial Business Insurance
Liquor Liability
Group Health