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Bob Walenta 

Sheila & Robin

Personal Lines Customer Service

 General Liability Quote 
Form: Business General Liability Insurance Quote
Business General Liability Insurance Quote




Contact Information
Name of Business:
Contact Name:
Address:
City:
State: Zip:
Business Phone:
Fax Number:
Contact Email Address:
Questions
Desired Limits: (Each Occurrence / General Aggregate)
(other limits may be available upon request)
$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000
What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products? %
What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment? %
Please indicate whether any of the following optional
coverages are desired: (the limits provided will be
the same as the limits chosen in number 1 above)
Employee Benefits Liability
YES NO
Liquor Liability
YES NO
If yes, please provide annual Liquor Receipts $
Hired and Non-owned Auto Liability
YES NO
Stop Gap Liability (if applicable)
YES NO
Limited International General Liability Extension Endorsement
YES NO
Please indicate whether any of the following exclusions
are desired
a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).
YES NO
b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).

YES NO
Wholesale Applicants ONLY
Are all goods manufactured domestically or by a company with a location in the US?
YES NO
If no, is Imported Products Liability Coverage desired?
YES NO
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products?
$
Do you do any repackaging, re-labeling, repair or re-manufacturing of products?
YES NO
Additional Comments
Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

 

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