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BUSINESS GENERAL LIABILITY QUESTIONNAIRE
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Email
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Record my email address with my response
APPLICANT NAME:
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BUSINESS NAME: & DBA(If Applicable)
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MAILING ADDRESS, STATE & ZIP
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PRINCIPAL CONTACT NAME & NUMBER:
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EFFECTIVE DATE OF COVERAGE REQUESTED:
MM
/
DD
/
YYYY
LOCATION ADDRESS:
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LEGAL ENTITY? (CHECK ONE)
Corporation
LLC
Partnership
Individual
Not for Profit
Other:
Date Business Established & # of years of Experience
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FEIN:
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SIC CODE:
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Description of Operation:
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Number of Full Time & Part TIme Employees
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Building Updates on Roof? HVAC / Elec / Plumb?
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Are there Sprinklers in the Building?
YES
No
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TYPE OF ALARM SYSTEM? Theft, Fire, Central?
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Sales/Receipts/Rental Income(Estimate)
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Payroll by Employee and Class if Contractor:
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IF CONTRACTOR - LIST 5 jobs and work completed:
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Any work subcontracted? If so % and type of work:
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Other Locations to be CovereD?
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Claims within 5 years for all policies: If so, are Loss Runs available?
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Quote Worker's Comp?
YES
NO
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Quote Business Auto? If quoting, need vehicles and driver info:
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Special Coverage, COI's , Conditions, Notes:
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