General Liability Quote

Contact Person *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Best Number to Contact *

Preferred Method of Contact *

Email Phone

Underwriting Information

Desired Limits Each Occurrence / General Aggregate *

$300,000/$600,000 $500,000/$1,000,000 1,000,000/$2,000,000

Other limits available upon request

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? *

Optional Coverages

Please indicate whether any of the following coverages are desired. (Limits provided will be the same as the limits chosen above)

Employee Benefits Liability *

Yes No

Hired and Non Owned Auto Liability *

Yes No

Liquor Liability *

Yes No

Stop Gap Liability *

Yes No

If Yes, please provide the annual Liquor Receipts $ *

Limited International General Liability Extension Endorsement *

Yes No

Please indicate whether any of the following exclusions are desired

General Liability Enhancement Endorsement (Adds additional insureds and other broadening coverages) *

Yes No

Beneral 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, relabeling, repair or re-manufactured of products? *

Yes No

Additional Comments

Please give any additional comments or questions *