BUSINESS OWNERS PROGRAM
General Liability Quote Request
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| Contact
Information |
| 1 |
First Name: |
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| 2 |
Last
Name: |
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| 3 |
Daytime
Telephone: |
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| 4 |
Evening
Telephone: |
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| 5 |
Email:
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| 6 |
Address: |
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| 7 |
City: |
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| 8 |
State: |
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| 9 |
Zip: |
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| 10 |
Desired Limits: (Each Occurrence
/ General Aggregate) (other limits may be available upon request)
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| 11 |
What percentage, if any,
of gross receipts/revenues is derived from service and/or installation
of products?
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| 12 |
\What percentage, if any,
of gross receipts/revenues is derived from the rental of any equipment?
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| 13 |
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). |
14 |
Employee Benefits Liability |
YES
NO
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15 |
Liquor Liability |
YES
NO
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16 |
If yes, please provide annual Liquor
Receipts $ |
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17 |
Hired and Non-owned Auto Liability
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YES
NO
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18 |
Stop Gap Liability (ND, OH, WA, WV
and WY only) |
YES
NO
|
19 |
Limited International General Liability
Extension Endorsement |
YES
NO
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| 20 |
Please indicate whether
any of the following exclusions are desired. |
| a) General Liability Enhancement
Endorsement (adds additional insureds and other broadening coverages). |
| |
YES
NO
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| b) General Liability Extended
Enhancement Endorsement (adds extended property damage and other broadening
coverages). |
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YES
NO
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| Wholesale Applicants
ONLY |
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| 21
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Are all goods manufactured domestically
or by a company with a location in the US?
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YES
NO
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22 |
If no, is Imported Products Liability Coverage desired? |
YES
NO
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| 23 |
If Imported Products Liability
Coverage is desired, what are the gross annual sales for foreign manufactured
products? $
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| 24 |
Do you do any repackaging, re-labeling,
repair or re-manufacturing of products? |
YES
NO
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| Comments
or Questions: |
| 25 |
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| 26 |
Deliver
quote via: |
E-Mail
Fax
Regular Mail
Telephone |
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