General Liability – Under 5 Minute Quote Worksheet

Company Name:
Address:
Phone:
Fax:
E-mail:
Contact:
Contact Phone:
Have you had any claims made in the last 4 years? YesNo
Type of business:
Annual Sales/receipts:
Business personal property value (i.e. computers, etc.): $
Build outs Replacement Cost:
Year office building was built (estimate OK):
Square footage of space to be insured (estimate OK):
Sprinklered? YesNo
Other locations? YesNo
If yes, other addresses:
Current Company:
Effective Date:
Your quick-quote/estimate will include: Business Liability, Business Personal Property (contents), Tenant Improvements (Build-Outs), Non-Owned and Hired Auto Liability, Employee Dishonesty plus other coverages and limits to be outlined on our quick-quote/estimate.
Date:
Name and Title:
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5890 Stoneridge Drive, Ste 209,
Pleasanton, CA 94588
CA Lic. 0C10853
(800) 987-1475 | (925) 416-1693