General Liability

GENERAL LIABILITY QUOTE FORM
First Name:
Last Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

UNDERWRITING INFORMATION
Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Annual Sub Costs:
Current Insurance Company:
Business License Number:
Building Square Footage:
License Type:
Years of Experience:
How many years have you operated under your current business name:
Have you use any other business names during the past 5 years:	NoYes
Please Describe the Nature of Your Business
Losses-Claims in the last 5 years:
If yes, date, amount paid and description of each loss-claim

GENERAL LIABILITY QUOTE FORM