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Business General Liability
Quote Request
Business General Liability Insurance Quote
Contact Information
Name of Business:
Contact Name:
Address:
City:
State:
Zip:
Business Phone:
Fax Number:
Contact Email Address:
Limits & Coverage
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 if optional coverages are desired:
(the limits provided will be the same as the limits chosen 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.
