General Liability Quote Form
Company Name
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Website
www.example.com
Entity Type
*
Individual
LLC
Corp
Partnership
S- Corp
Tax ID Number
*
Do you lease or own your location
*
Lease
Own
Work from home
Square feet of location
*
Description of Operations
*
What year did your business start
*
How many years experience do you have
*
How many full time employees
*
Including owners
How many part time employees
*
Including owners
Do you use subcontractors or 1099 employees for any of your work
*
Yes
No
What is your annual revenue
*
Gross revenue
How much do you pay to subcontractors or 1099s
*
Gross paid
Owner Name
*
First Name
Last Name
Date of Birth
*
Owner
Have you ever been canceled or nonrenewed
*
Yes
No
Any claims in the past 5 years
*
Yes
No
Prior Carrier
*
Name of company
What liability limits do you need
*
Dec Page of current policy
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Loss run report
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