GL/PROP Quote Form

GL/PROP Questionnaire Quote Form

Please fill the form accurately for better assistance
Name*

First NameLast Name
Business Name *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Number*
E-mail*
example@example.com
Describe Business *
Describe Business in Detail

Name of Owner(s)*
List name
Type of Business*

IndividualPartnershipCorporationOther
If Other, describe:
Describe Business in Detail
Year Business Established *
Years Experience in Field *
Hours of Operation *
Days of Operation *
Current Insurance and Coverage *
If any claims, how much was paid out?

Employee Information
Number of Employees *
Payroll per Employee *

Percentage of Business Receipt
Commercial %*
Residential %*
Liquor % *
Food % *

Building Information
Year Built *
Percentage Occupied %*
Sq Foot *
Roof Type *
Age of Roof*
Age of Plumbing *
Age of Electrical *
Alarmed *

Coverage Amount Requested
General Liability $*
Building $*
Business Property $*
Garage Liability $*
Per Vehicle $___________Max Limit *
Max Amount for all vehicles *
Cargo (Truckers) $*
Inland Marine $*
Any tools over $1000 need to be Scheduled
Should be Empty: