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General Liability Quote Form


Please complete form to the best of your ability

Contact Information
First Name
Required
Last Name
Required
Social Security Number
Optional
Company Name
Required
Federal ID
Required
Company Owner
Required
E-Mail Address
Required
Primary Phone Number
Required
Alternate Phone Number
Optional
Street
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City
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State
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ZIP / Postal Code
Required
Additional Information
Business Type
Required
Limits of Liability
Required
Do you currently have insurance?
Required
If "Yes", who is your current insurance provider?
Optional
Expiration Date
Optional
/ /
Year Business Established
Required
Years of Experience
Required
Annual Employee Payroll
Required
Detail description of operations
Required
Owners' Annual Payroll
Required
Do you use subcontractors?
Required
If "Yes", what is the percentage used?
Optional
If "Yes", what is the breakdown of subcontractors by category? (Ex. Electricians, Plumber, Etc.)
Optional
If "Yes", do you require your subconractors to have insurance?
Optional
If "Yes", do you require them to carry the same amount of coverage?
Optional
If "Yes", do you obtain a certificate of insurance from subcontractors?
Optional
Optional Coverage
Property Information
Amount of Desired Building Coverage
Optional
Amount of Desired Contents Coverage
Optional
Property Address
Optional
Property City
Optional
Property State
Optional
Property Zip/ Postal Code
Optional
Property County
Optional
Construction Type
Optional
If "Other", please explain
Optional
Year Built
Optional
Square Footage
Optional
Roof Type
Optional
If "Other", please explain
Optional
# of Stories
Optional
Occupancy
Optional
Has the exterior paint been updated since the original construction date?
Optional
If "Yes", when?
Optional
Has the heating and cooling system been updated since the original date of construction?
Optional
If "Yes", when?
Optional
Has the plumbing been updated since the original date of construction?
Optional
If "Yes", when?
Optional
Has the roof been updated since the original date of construction?
Optional
If "Yes", when?
Optional
Has the wiring been updated since the original date of construction?
Optional
If "Yes", when?
Optional
Monitored Alarm System?
Optional
If "Yes", can you provide certificate of installation and service?
Optional
Hard wired smoke detectors installed?
Optional
Do you have fire extinguishers?
Optional
Are double cylinder dead bolt locks installed on the doors?
Optional
Are security guards on site?
Optional
If "Yes", what type?
Optional
Additional Information
How did you hear about us?
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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