EmailMe Form - BUSINESS GENERAL LIABILITY INSURANCE QUOTE

Business Owner
First Last
Business Name
Type of Organization
Business Tax ID Number (EIN or SSN)
Business Location

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Phone Number
### - ### - ####
Fax Number
### - ### - ####
Email
Description of Operations
Years in Business
Estimated Annual Revenue
Estimated Annual Payroll
Number of Owners/Partners
Number of Full Time Employees
Number of Part Time Employees
CURRENT POLICY INFORMATION
Current Insurance Carrier
Policy Expiration
Current Premium
Years Insured
Loss History prior 3 years (date, type, amount paid, status)
List ALL losses for past 3 years: Date, Description, Amount
Limits of Liability Needed
BUSINESS PROPERTY AND CONTENTS QUOTE INFORMATION
Property Coverage Quote
Building Age (Years)
Building Square Footage
Number of Stories
Exterior Walls
Describe Any Building Improvements (A/C, Plumbing, Wiring, Roof, etc.) with Date Completed
Occupancy
Square Feet Occupied as Owner or Tenant
Building Estimated Value
Protection Devices
Installed
Monitored Burglar Alarm
Monitored Fire Alarm
Sprinklers
Smoke Detectors
Fire Extringuishers
Contents Coverage Quote
Describe Business Contents in Detail
Replacement Value of Business Contents
Remarks or Additional Information
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