General Liability App

General Information

Your Company

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Website

Detailed Description of your Business:

Years in Business

Estimated Annual Revenue

Number of Locations

Number of Employees

Estimated Annual Payroll

Subcontractors Used

Annual Cost of Subcontrators

Company Name (Not Agency)

Policy Expiration Date

Years Insured

Premium Amt ($)

Any Claims in Last 3 Years? If Yes, Please Describe:

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(i.e. Loss Runs, Certificate Requirements, etc.)