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General Liability
About Your Company
Company Name*
Your First Name*
Last Name*
Email*
Email address (retype)*
Street Address*
City*
Select State*
Zip*
Phone (Day)*
Phone (Evening)
Fax
When would you like to be contacted? No Preference Morning
Afternoon       Evening
About Your Business
Sole Propietorship Partnership Corporation LLC
Association
Do you currently have a Commercial Liability policy? Yes No
  If "Yes", when does your current policy expire?
  If "Yes," who are you currently insured with?
Do You Own, Lease, or Rent the Business Location ?
Approximate Annual Gross Revenue
Describe the operations of your Business:

Approximate Annual Gross Revenue
Approximate Annual Payroll
Although the building will not be covered, we need to know about the building, if any, in which your business operates:
Approximate Year Property was Built
Total Square Footage of Location
Updates (If you are the tenant, please guestimate)
Roof (Enter year last updated)
Electric (Enter year last updated)
Heating (Enter year last updated)
Plumbing (Enter year last updated)
Alarms
Burglar Alarm Central Station Local None
Fire Alarm Central Station Local None
Sprinklered? Yes No
Preferred Deductible: $500   $1000 $1500 $2500
$5000 Other
   
Has your company had any claims in the last 3 years?
 Yes No
  If "Yes", briefly explain:
Any Comments / Questions?
 
   
 
 
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