General Liability Quote

Business General Liability Insurance Quote

Name of Business:

Contact Name:

Address:

City:

State:

Zip:

Business Phone:

Fax Number:

Contact Email Address:

Questions

Desired Limits: (Each Occurrence / General Aggregate)
(other limits may be available upon request)

$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000

What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?

What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?

Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above)

Employee Benefits Liability

YES
NO

Liquor Liability

YES
NO

If yes, please provide annual Liquor Receipts $

Hired and Non-owned Auto Liability

YES
NO

Stop Gap Liability (if applicable)

YES
NO

Limited International General Liability Extension Endorsement

YES
NO

Please indicate whether any of the following exclusions are desired.

a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).

YES
NO

b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).

YES
NO

Wholesale Applicants ONLY

Are all goods manufactured domestically or by a company with a location in the US?

YES
NO

If no, is Imported Products Liability Coverage desired?

YES
NO

If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products? $

Do you do any repackaging, re-labeling, repair or re-manufacturing of products?

YES
NO

Additional Comments

Please give any additional comments or questions

No
coverage of any kind is bound or implied by submitting information
via this online form

Information from you and other sources, such as your driving,
claims and insurance histories, may be used to calculate an
accurate price for your insurance.
We will not distribute information to other parties other
than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.