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General Liabilty
Quote

We would like to provide you with a free, no-obligation general liability insurance quote. Please provide as much information possible for most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Business : 
Inspection Contact Name : 
Mailing Address : 

City :

 State:  Zip: 
Location Address

City : 		 State:  Zip: 
Business Phone :  Fax Number :
Contact Email Address : 
Business Status :     Years in Business:
Current Insurance Information
Company Name
(not agency) :
Effective Date (DD/MM/YYYY):    Expiration Date: (DD/MM/YYYY)
Please List Any Other Previous Carriers Over The Past 3 Years Below
Carrier Name:    Premium: $
Carrier Name:    Premium: $
Project/Work Information
Please write a Description of Operations below:
What percentage of your work is:
(each line must total 100%) 		Commercial %  Industrial %  Residential %
New Construction %  Remodel/Additions %
What percentage of your work is as a: General Contractor %  Subcontractor %  Residential %
What percentage of your work is: Subcontracted Out %  Sub Costs $%  Residential %
Do you collect certificates of
insurance at a $1,000,000 limit?: 		Yes    No
Receipts / Payroll Dollar Value Info
Gross receipts for the past 3 years:
and the next 12 months: 		(3'rd year prior) $   (2'nd year prior) $
(Last 12 months) $   (Next 12 months) $
Number of owners/officers/partners active
at the job site or supervising:
Payrolls of employees excluding owners,
officers, partners & clerical:
Dollar value of average Job completed
incl. all materials, labor & equipment:
Describe any project(s) underway or planned for the next year, including values below:
Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums,
townhouses, apartments, or single family tract developments of two (2) or more?: 		Yes    No
Have you ever been named in litigation regarding faulty construction?: Yes    No
Are there any claims or legal actions pending?: Yes    No
Do any of the entities named in the application have knowledge of any pre-existing
act, omission, event, condition or damages to any person or property that may
potentially give rise to any future claim or legal action against any such entity?: 		Yes    No
Claims History
Enter all claims or occurrences that may gve rise to claims for the prior 3 years.
This information is kept strictly confidential
Claim #1 claim status:   Yes    No
Date of Occurence:   Date of Claim:
Type/Description of Occuerence or Claim
Amount paid on your behalf: $    Amount reserved on behalf: $
Claim #2 claim status:   Yes    No
Date of Occurence:   Date of Claim:
Type/Description of Occuarence or Claim
Amount paid on your behalf: $    Amount reserved on behalf: $
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here
Please click on the "Submit Quote" button to send your quote request
One of our representatives will respond to your submission as soon as possible