General Liability Quote


Company Name
Insured's First Name
Insured's Last Name
Mailing Address
Mailing City
Mailing State
Mailing Zip
Date of Birth
Month
Day
Year
Social Security Number (xxx xx xxxx)
Additional Name
Date of Birth
Month
Day
Year
Social Security Number (xxx xx xxxx)
Type of Business
Date Business Started
Month
Day
Year
Mailing Address
City
Parish
Zip
Business Address
Home Phone
Business Phone
Cell Phone
Email (Enter 'none@none.com' if you don't have email)

Email (Reenter)

2nd Email (Enter 'none@none.com' if you don't have a second email)

2nd Email (Reenter)

Years in Business
Years Experience
Federal Tax ID or SSN
Gross Annual Revenue
Nature of Business


Job Description


W2
1099
Full Time Employees?
Number of Full Time Employees
Estimated Annual Full Time Payroll
$
Part Time Employees?
Number of Part Time Employees
Estimated Annual Part Time Payroll
$
Subcontracted Work?

      If you subcontract work answer the following:
      
      
Annual Subcontracted Work Amount
$
What type of work is subcontracted?
Prior Coverage

      If you have prior coverage please complete the following:
      Company
      
      Expiration Date
      
      Loss Run
      
Have you had any claims in the past 5 years?

      If you have had a claim in the past 5 years, please complete the following:
      Date
      
      Type
      
      Amount
      
Additional Comments
Completed By
Comments

Insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise. No binder. Insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly'by a licensed agent.