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207-358-7408
978-225-7933
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207-358-7408
978-225-7933
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General Liability Quote
Home
General Liability Quote
General Information
Fields marked (*) are mandatory.
Name of Business
*
Type Of Liability
*
General
Liquor
Professional
Inspection Contact Name
*
Mailing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Location Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Claim Status
Open
Closed
Business Phone
Fax
Contact Email Address
Business Status
Years In Business
Current Insurance Information
Company Name (not your agency)
Premium
Effective Date
MM
DD
YYYY
Expiration Date
MM
DD
YYYY
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name
Premium
Carrier Name
Premium
Project/Work Information
Please Write a Description of Operations
What Percentage of Your Work is: (each line must total 100%)
Commercial (%)
Industrial (%)
Residential (%)
New Construction (%)
Remodel/Additions (%)
What Percentage of Your Work is as a
General Contractor (%)
Subcontractor (%)
What Percentage of Your Work is
Subcontracted Out (%)
Sub Costs (%)
Do You Collect Certificates of Insurance at a $1,000,000 limit?
Yes
No
Receipts / Payroll / Dollar Value Info
Gross Receipts for the Past 3 Years and the Next 12 Months
(3rd yr prior) $
(2nd yr prior) $
(Last 12 mnths) $
(Next 12 mnths) $
Number of owners/officers/partners active at the job site or supervising
Payroll of employees excluding owners, officers, partners and clerical ($)
Dollar value of average job completed including all materials, lab or equipment ($)
Describe any projects underway or planned for the next year, including values
Miscellaneous and Legal Info
Have you ever performed ground up construction involving condiminiums, townhouses, apartments, or single family tract developments of two (2) or more?
Yes
No
Have you ever been named in litigation regarding faulty construction?
Yes
No
Third Choice
Are there any claims or legal actions pending?
Yes
No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition, or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?
Yes
No
Claims History
Enter all claims or occurences that may give rise to claims for the prior 3 years. This information is kept strictly confidential.
Claim #1
Claim Status
Open
Closed
Date of Occurance
MM
DD
YYYY
Date of Claim
MM
DD
YYYY
Type/Description of Occurance or Claim
Amount paid on your behalf:
Amount reserved on behalf:
Claim #2
Claim Status:
Closed
Open
Date of Occurance
MM
DD
YYYY
Date of Claim
MM
DD
YYYY
Amount paid on your behalf:
Amount reserved on behalf:
Additional Comments
Please give any additional comments you feel appropriate for this quotation: