Commercial Property / General Liability Form
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Business Information
Business Name
Contact Person Name
Contact Number
Please enter a valid phone number.
Email
example@example.com
Entity Type:
LLC
Corp
Sole Proprietor
Partnership
Other
Industry:
Retail
Contractor
Office
Restaurant
Other
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years in Business
Number of Employees
Annual Revenue
Under $100K
$100K - $500K
$500K - $1 Million
Over $1 Million
Property Information
Building Ownership:
Owned
Leased
Home-Based
Other
Building Type
Standalone
Multi-Tenant
Office
Warehouse
Other
Year Built
Square Footage
Construction Type
Frame
Brick
Masonry
Other
Fire Protection
Smoke Detectors
Alarm
Sprinkler
Other
Security System
Yes
No
Other
Coverage Options
General Liability Limit:
$ 1 Million - $ 2 Million
$ 2 Million - $ 4 Million
Custom
None
Custom General Liability Limit:
Click all the coverages you need.
Property Coverage
Business Interruption Coverage
Professional liability (E&O)
Workers' Compensation
Commercial Auto
Cyber Liability
Other
Insurance & Claims
Current Carrier and Expiration Date:
Any Claims in the Last 5 Years?
Provide details please.
Additional Space:
Use this space to provide any information you feel is necessary.
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