/ GENERAL LIABILITY APPLICATION
Time To Call:
Number Full-Time Employees
Number Part-Time Employees
Years in Business:
Gross Annual Sales: $
Gross Annual Payroll: $
|Describe the Nature of Business:
Name (not agency):
Policy Expiration Date:
Amount insured for: $
than 3 years, prior company:
Losses/Dates (last 3 years):
Include Description, Date, Amount
Square footage of your business area?
Square footage of the entire
Age of roof:
Stories in building:
Updated Heating or Plumbing?
Within 1000 feet of a fire hydrant?
Within 5 miles of a fire station?
Central station Burglar Alarm?
Automatic sprinkler system covering 100% of your
give any additional comments you feel appropriate for this
quotation. If you have additional locations, please enter
as much information as you can here.