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	General Liability

Business General Liability Insurance Quote

Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax Number:
Contact Email Address:

Questions

Desired Limits: (Each Occurrence / General Aggregate)
(other limits may be available upon request)

$300,000/$600,000	$500,000/$1,000,000	$1,000,000/$2,000,000
What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?		%
What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?		%

Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above)

Employee Benefits Liability	YES NO
Liquor Liability	YES NO
If yes, please provide annual Liquor Receipts $
Hired and Non-owned Auto Liability	YES NO
Stop Gap Liability (if applicable)	YES NO
Limited International General Liability Extension Endorsement	YES NO

Please indicate whether any of the following exclusions are desired.

a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).
	YES NO
b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).
	YES NO

Wholesale Applicants ONLY

Are all goods manufactured domestically or by a company with a location in the US?	YES NO
If no, is Imported Products Liability Coverage desired?	YES NO
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products?	$
Do you do any repackaging, re-labeling, repair or re-manufacturing of products?	YES NO

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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