Form : Liability Insurance Quote Professional & General Business Liability Insurance Quote First & Last Name * Mailing Address City, State & Zip E-Mail Address * Telephone Fax Business Name Federal Tax ID Business Start Date (MM/YYYY) Business Type IndividualPartnershipCorporateOther Current Insurance Company Name Policy Exp. Date Any Claims in Last 3 years?(if Yes, please describe) Est. Annual Gross Receipts Est. Annual Employee Payroll Est. Annual Sub-Out Liability Limit $100,000$500,000$1,000,000$2,000,000 List any other coverages needed Describe the type of work you do (business, product, services) Business Property InformationOffice Physical Address City, State, Zip Code Own or Lease the location? NoOwnLease Year built If you do not have the building information, please provide the landlord or property management contact information, e.g. name, phone # and email.Number of stories in the building Building total square feet Square feet occupied by your company Building Construction type FrameStuccoMasonry/BrickTile up ConcreteFire Resistive ConcreteReinforced ConcreteSteel FrameOther Is the building in a shopping center or mall (Y/N)? NoYes Is there a basement (Y/N) NoYes If there is a basement, what is the square footage Building occupancy rate (in %) Does the building/office has sprinklers (Y/N)? If the building/office has sprinkler, what percentage of the building/office has sprinklers Type of fire alarm? NoneLocalCentral Station Type of Burglar alarm? NoneLocalCentral Station Type of roof ShingleWoodCompositeTileFlatMetal Date Roof was last updated Date Electrical/Wiring was last updated Date Plumbing was last updated Date Heating was last updated Any Boiler in the building (Y/N)? Are you responsible for the Parking Lot space (Y/N)? NoYes If yes, state the Parking Lot Square Footage What type of business is operate to the left of your business (e.g, restaurant, etc) & distance in feet What type of business is operate to the right of your business (e.g, restaurant, etc) & distance in feet What type of business is operate in front of your business (e.g, restaurant, etc) & distance in feet What type of business is operate to the rear of your business (e.g, restaurant, etc) & distance in feet Certificate of Liability holder name & address Note Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank