Professional Service Insurance

Business/Commercial

Commercial Liability Quote

GENERAL LIABILITY QUESTIONAIRE:

Date:

Business Name:

Owner / Principal Name

Mailing Address

Business Location

Nature of Business

No. Years In Business

EIN#:

Email:

Business #

Home #:

Cell #:

COVERAGE REQUIRED:

LIMIT

Comprehensive General Liability (A, B, C)	$
Manufacturers and Contractors	$
Independent Contractors (IC)	$
Owners, Landlords & Tenants/Premises/Operation (OLT)	$
Contractual – Designed Contractors	$
Product/Completed Operation (PR)	$
Hired/Non-Owned Automobile Liability	$
Premises Medical Payments (AC)	$
Personal and Advertising Injury (PI)	$
Employers Liability (Stop Gap)	$
Storekeepers Liability	$
Garage keepers Liability	$
Fire Legal (FL)	$
Other:___________________________	$

INFORMATION REQUIRED:

Annual Payroll	$
Area (Sq. Ft.)	$
Gross Receipts	$	- Premises Operations
Contract Cost	$	- Independent Contractors
Contract Cost	$	- Contractual

Additional Insured(s):

Loss paid/Outstanding last 5 years.:

Date of Loss:
Amt. Paid/Outstanding:
Loss Description: