Family Owned Since 1899
Personal & Business Insurance

General Liability Insurance Quote


1. Contact Information
  Contact Name
Name of Business
Address
Address 2
City, State, Zip    
Phone number
Fax
Email Address


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2. Desired Limits: (Each Occurrence / General Aggregate)
(other limits may be available upon request)
$1,000,000/$2,000,000
$2,000,000/$4,000,000
3. Service: What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?
4. Rental: What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?


5. Optional Coverages: 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 (ND, OH, WA, WV and WY only) Yes
No
Limited International General Liability Extension Endorsement Yes
No


6. 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? $
7. Wholesale Applicants ONLY Do you do any repackaging, re-labeling, repair or re-manufacturing of products? Yes
No