General Liability Insurance Quote Form

1. Name of owner:

2. DBA (doing business as) name:

Please give one: State ID#: Corporation #: or SS#:

4. Phone # w/area code: 5. Fax # w/area code:

6. Email address: 7. Best time to call : a.m./p.m.

8. Street address, city, state and zip Code:

9. Years in business:

10. Square footage of Office Space /Building:

11. Building Type (# of stories, Steel, Frame-Stucco, Age of building):

12. Description of business:	13. Number of employees:
	14. Amount of payroll $:

15. Last years gross receipts $:

16. Any losses in the past three years? (yes/no):
(If so, what's been done to correct the cause of loss?):

17. Amount of coverage requested?:

18. Name of lessor, or additional insured:

19. Is there an alarm system? (yes/no):
20. Fire Precautions (fire alarm/smoke detectors):
What's the fire district?:

21. Please name present insurance company and policy number: