Application – Affordable General Liability Insurance

General Liability Application

Entry Date
Date Format: MM slash DD slash YYYY
Industry
Class
Controllling Agent
Name*
Business Name
Briefly describe your business operations.*

Phone*
Email*
Entity Type*
Year Business Started*

Annual Gross Sales (Estimated)*
Gross sales are the total amounts (before expenses) that a company earns and records from the sales of its products or services.
Number of Employees*
Annual Employee Payroll (Estimated)*
Do not include payroll for owners, officers or partners.
What percentage of your gross sales are paid to subcontractors?*

Location Address*
Street Address City State / Province / Region ZIP / Postal Code
Is this a home based business?*
- Yes
- No

In addition to General Liability, please indicate any other quotes would like us to include.
- Professional Liability (E&O)
- Workers Compensation
- Commercial Auto
- Property

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Questions? Call 800-858-1315