* = Required Information
GENERAL LIABILITY QUESTIONNAIRE
Date
Name of Business
*
Address
*
Name of Owner
*
Home Phone #
*
Cell Phone #
Type of work done by insured
If more than one type
%
%
%
How long in business
Years experienced in this field
Previous Carrier
Coverage Desired
$100,000
$300,000
$500,000
Or
$1,000,000
$2,000,000
Annual Payroll
Number of Employees
F/T
P/T
Annual Gross Sales
Any Losses
Date of Loss
Description of Loss
Amount Paid
Is insured an:
Individual (DBA)
Corporation:
Inc.
Corp.
Percentage of work done in new york city
Percentage of work done outside new york city
What percentage of work is commercial
What percentage of work is residential
Agency Requesting Quote
Person Requesting Quote
Agency Phone Number
*
Submit