Contractors Insurance 

BUSINESS OWNERS PROGRAM
General Liability Quote Request

 Contact Information
1
First Name:
2
Last Name:
3
Daytime Telephone:
4
Evening Telephone:
5
Email:
6
Address:
7
City:
8
State:
9
Zip:
 
10
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    
 
11
What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?
 
12
\What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?
 
13
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).
14
Employee Benefits Liability
YES NO
15
Liquor Liability
YES NO
16
If yes, please provide annual Liquor Receipts $
17
Hired and Non-owned Auto Liability
YES NO
18
Stop Gap Liability (ND, OH, WA, WV and WY only)
YES NO
19
Limited International General Liability Extension Endorsement
YES NO
 
20

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
21
Are all goods manufactured domestically or by a company with a location in the US?
YES NO
22
If no, is Imported Products Liability Coverage desired?
YES NO
23
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products? $
 
24
Do you do any repackaging, re-labeling, repair or re-manufacturing of products?
YES NO
Comments or Questions:
25
26
Deliver quote via: 
E-Mail Fax Regular Mail Telephone
No coverage of any kind is bound or implied by submitting information via this online form
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YES! I Agree