Professional
Liability and/or General Liability Insurance Quote Request |
ABOUT THE OWNER / PRINCIPAL |
Company Name:
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First Name:
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Last Name: |
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Address: |
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City: |
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State: |
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Phone: |
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Zip Code: |
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E-mail: |
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Confirm E-mail: |
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ABOUT THE BUSINESS |
Name
of Business: |
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Location: |
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Description of Business: |
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Year Started: |
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Years experience in industry: |
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Type of
Insurance Request: |
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PROFESSIONAL LIABILITY
(E&O) SECTION - OPTIONAL |
Professional Liability Limits: |
$
($250,000/$250,000 will be quoted if nothing is entered) |
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Number of Partners/Execs: |
(if you only have owners, put the number here) |
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Full Time Employees (not
owners): |
Part-Time: |
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# of independent contractors that work for you
exclusively: |
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What
types of clients do you service: |
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Do you belong to
any professional associations? |
(if known) |
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Gross Receipts: |
Prior Year $
(if new business, write NEW and estimate an amount) |
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Current
Year $
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Estimates for Next
Year $
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Annual Payroll: |
$
(if none, write "none") |
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Claims: |
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Other: |
Do your customers sign a
contract or written agreement?
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Do you use any independent contractors that are
not working exclusively for you? |
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Retroactive Coverage
Options: |
If you currently
have errors and omissions insurance in force, please let us know
with which carrier and the retroactive date shown on your
declarations page (you can provide this information later):
Enter Info Here:
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COMMERCIAL GENERAL LIABILITY SECTION - OPTIONAL |
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General Liability Limits: |
$
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Space Occupied (sq feet): |
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Building Security System? |
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PROPERTY INSURANCE -
OPTIONAL |
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*** |
Do you currently
have insurance (if yes, with what carrier?
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Current Premium:
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Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. |
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Notary Insurance - Mobile Notary
Insurance - Errors and Omissions Insurance - General Liability Insurance for
Notaries |
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. COVERAGES VARY BY POLICY. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
Copyright 2013 Stratum
Insurance Agency, LLC |