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Commercial Business
Note:
* Indicates required Information
Business Information
*This quote request is for:
Commercial General Liability
*Name of Business
* Business Owner Name:
*Email Address
*Address:
*City:
*State:
*Zip Code:
Business Phone:
Business Fax:
*Describe the nature of
this business
*This Business is a
Sole Proprietorship
Partnership
Limited Partnership
Corporation
How many owners of this business:
How many years has this business been in operation ?
Less than 1 year
1 - 5 years
6 - 10 years
More than 10 years
*In which State(s) does the business operate ?
All 50 States
US-AK
US-AL
US-AR
US-AZ
US-CA
US-CO
US-CT
US-DC
US-DE
US-FL
US-GA
US-HI
US-IA
US-ID
US-IL
US-IN
US-KS
US-KY
US-LA
US-MA
US-OK
US-MD
US-ME
US-MI
US-MN
US-MO
US-MS
US-MT
US-NC
US-ND
US-NE
US-NH
US-NJ
US-NM
US-NV
US-NY
US-OK
US-OR
US-PA
US-RI
US-SC
US-SD
US-TN
US-TX
US-UT
US-VA
US-VT
US-WA
US-WI
US-WV
US-WY
hold down control key to make multiple selections
*Which Country(s) does the business operate in ?
*Does the business use sub-contractors ?
Yes
No
*If yes, what percent of annual income goes to sub-contractors
%
*Does this business keep certificates of insurance on all sub-contractors?
Yes
No
*Does this business have employees ?
Yes
No
If yes, how many ?
Annual Payroll
(Do not included owners' payroll)
*Does this business have a monitored alarm system?
(i.e. office equipment, tools, etc.)
Yes
No
*Does this business need content coverage ?
(i.e. office equipment, tools, etc.)
Yes
No
If yes, how much ?
*Does this business need glass or sign coverage ?
Yes
No
If yes, how much ?
*Does this business own or lease this property ?
Own
Lease
If Lease,provide square footage leased
Prior Insurance Data
*Any prior insurance for this business in the last 12 months ?
Yes
No
if yes, with who
*Any claims for this business in the last 3 years ?
Yes
No
*If yes give details
(i.e. date of claim, amount paid and how claim occurred )
Coverage Liability Limits
*Combined Limits
$100,000
$200,000
$300,000
$500,000
$1,000,000
$1,000,000+
*Does the business have to list additional insured's?
Yes
No
*If yes, how many ?
Other Coverage Needed
*Does the business require other coverage(s)
Yes
No
*If yes, give detailed description.
*Email my quote
Yes
No
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