General Liability Quote Request


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Please send this information with attention to:

i. Contact Information: (* = required fields)

*Business Name
*Office Phone:
*Contact Name:
Cell Phone:
*Business Address:
Fax #:
*City:
   
*State:
 *Zip:    

*Email Address:
*Confirmation of Email Address:

When is the best time to reach you? What is the best way to reach you?

ii. Prior Insurance Information:

Are you currently insured?
  If yes, then:
  Who is your current Insurance Carrier?
  Approximately how much are you paying for your Commercial Insurance Coverage?

iii. Business Information - Tell us about your business:

What type of entity is your business?

How many officers/owners are there in your business?

Please give a detailed description of your business operations?
The more information you give will help us best classify your business. (required field)

iv. Liability Information:

What Liability limits do you need?

v. Gross Receipts Information:

How much estimated, annual sales [before taxes & payroll] to you plan to bring in during the next year for each type of work you do?
  For example:
    For Plumbing operations, I plan on making $200,000.
    For Electrical operations, I plan on making $150,000.
    For Interior Trim operations, I plan on making $25,000.
 
Type of Work
Estimated, Annual Sales
 
 
 
 
 
 

vi. Payroll Information:

Please give a one or two word job description for each type of employee with their estimated, annual payroll.
  For example:
    For 2 Clerical Employees, I pay $60,000 in total.
    For 5 Sales Associates, I pay $80,000 in total.
    For 6 Installation Technicians, I pay $120,000 in total.
   
# of Employees
Type of Employees
Estimated, Annual Payroll
   
   
   
   
   
   

vii. Sub-Contracted Work Information:

Do you use sub-contractors? Yes No
  If yes, then:
  What percent of the work is sub-contracted (1-100)?
  Are all those sub-contractors insured? Yes No -- If no, what percent of those are uninsured (1-100)?

viii. Other Coverages:

Workers' Compensation
Business Property and/or Building Coverage
Business Automobile
Other

 
 
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