October 20, 2017

General Liability Quote

General Information
Contact Name *
Contact Email *
How did you hear about us? *

Business Name *
Mailing Address *
City *
State *
Zip *
County
Business Phone
Cell Phone
Fax
Website
Preferred Method of Contact? Business Phone  Cell Phone  Email  Fax
Current Insurance Company
Insurance Company Name
Policy Expiration Date
Policy Number
Business Information
FEIN #
Business Type
How long in Business? (yrs)
How many locations?
Please give a description of your business operations
Coverage Information
Per Claim Limits
Aggregate Limits
Product Liability & Completed Operations Aggregate
Damage to Rented Premises
Medical Payments Limit
Employee Benefits Liability Yes  No
Data Breach Coverage Yes  No
Other - Please Specify
Property Damage Deductible
Bodily Injury Deductible
Describe any claims in the past 3 years
Premises Information
Property Address - if different from mailing address
Occupancy Status Owner  Tenant
Total Sales
Total Payroll
Number of employees
Square Feet
Subcontractors
Do you use any subcontractors? Yes  No
What is your sub cost?
Do all subs have their own insurance? Yes  No
Do you require certificates of insurance from all subs? Yes  No
Additional Insureds
Any additional insureds? Yes  No
If yes above - please provide name and address for each additional insured
General Liability Questions
For any "Yes" answers please explain at the bottom of this section.
1. Any medical facilities provided or medical professionals employed or contracted? Yes  No
2. Any exposure to radioactive/nuclear materials? Yes  No
3. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material (e.g. landfills, wastes, fuel tanks, etc.)? Yes  No
4. Any operations sold, acquired, or discontinued in last five years? Yes  No
5. Machinery or equipment loaned or rented to others? Yes  No
6. Any watercraft, docks, floats owned, hired or leased? Yes  No
7. Any parking facilities owned/rented? Yes  No
8. Is a fee charged for parking? Yes  No
9. Recreation facilities provided? Yes  No
10. Is there a swimming pool on the premises? Yes  No
11. Sporting or social events sponsored? Yes  No
12. Any structural alterations contemplated? Yes  No
13. Any demolition exposure contemplated? Yes  No
14. Has applicant been active or is currently active in joint ventures? Yes  No
15. Do you lease employees to or from other employers? Yes  No
16. Is there a labor interchange with any other business or subsidiaries? Yes  No
17. Are Day Care facilities operated or controlled? Yes  No
18. Have any crimes occurred or been attempted on your premises within the last three years? Yes  No
19. Is there a formal, written safety and security policy in effect? Yes  No
20. Does the businesses' promotional literature make any representations about the safety or security of the premises? Yes  No
If you answered "Yes" to any question above - please explain.
Other Questions
For any "Yes" answers please explain at the bottom of this section.
1a. Is the applicant a subsidiary of another entity? Yes  No
1b. Does the applicant have any subsidiaries? Yes  No
2. Is a formal safety plan in operation? Yes  No
3. Any exposure to flammables, explosives, chemicals? Yes  No
4. Any other insurance applied for with this company? Yes  No
5. Any policy or coverage declined, cancelled or non-renewed during the prior three years for any premises or operation? Yes  No
6. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Yes  No
7. During the last five years, has any applicant been indicted for or convicted of any degree of crime of fraud, bribery, arson or any other arson-related crime in connection with this or any other property? Yes  No
8. Any uncorrected fire and/or safety code violations? Yes  No
9. Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy in the last 5 years? Yes  No
10. Has applicant had a judgement or lien during the last 5 years? Yes  No
11. Has business been placed in a trust? Yes  No
12. Any foreign operations, foreign products dist distributed in the USA, or US products sold/distributed in foreign countries? Yes  No
13. Does applicant have other business ventures for which coverage is not requested? Yes  No
If you answered "Yes" to any question above - please explain.

Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.