APPLICATION

General liability application

Premises and operations coverage for small businesses, with certificates for landlords and customers.

Business information

Legal business name

DBA, if different

Entity type

Years in business

Federal EIN Leave blank for a sole proprietor

Owner Social Security number Used to rate the policy. Leave blank if you do not have one. Sent and stored encrypted.

Contact name

Phone

Business address

City

State

ZIP code

Operations

Describe the work you do

Premises

Number of employees

Annual payroll

Annual revenue

Annual cost of subcontractors

Limit requested

Certificate holders and additional insureds Landlord, general contractor, city

Also quote

Prior insurance

Current or most recent carrier

Liability claims in the last 5 years Date, type and amount, or "none"

When do you need coverage to start?

Anything else

Notes for the agent