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:
Zip Code:
 Phone:
Cell/Alternate Phone:
  Email Address:  
Best Time To Contact:
Contact By:

Business Information
Business Name:
Years Experience:
Year Business Started:
Entity Type:
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:
Professional Liability
Products/Completed Opps Liability:
Property Rented:
Medical Expenses:
Deductible:
Payroll:
Sales:

Premise Information
Street:
City:
County:
Zip Code
City Limits
Ownership Interest:
Year Built:
Square Footage:
Part Occupied:
Construction Type:
Roof Type:
Monitored Alarm:
Additional Locations:
Enter the information requested above for any additional locations below:

Rating Information
Are you a subsidiary of another entity?:  
Do you have a formal safety program?:  
Any Exposures to Flammables, Explosives, Chemicals?:  
Any Catastrophic Exposures?:
Any policy or coverage declined, cancelled or non-renewed in the past 3 years?:  
Any past losses due to sexual abuse or molestation allegations, discrimination, negligent hiring?:  
During the past 10 years, has any applicant been convicted of any degree of the crime of arson?:  
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?:  

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: