Commercial General Liability Insurance Quote Request

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Quick-Quote.me General Liability Insurance With Several Leading Insurance Companies

To Get A Quick-Quote Complete The Below Underwriting & Rating Information Form

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Commercial / Business General Liability Insurance Quote Request

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured:

General Information:

* Business Name

Type of Business :

*Contract - Full Name:

Describe Operations :

* Title / Position:

Business Model:

* Employers Federal Tax Id # (FEIN)

Select Any Other Kinds Of Coverage That You Want Us To Quote:

*Contact Phone:

Cell #

Business Owners Policy : Package Policy That Combines

Building / Contents / Liability

Into A Single Policy

Flood Insurance :

Workers Comp: Fidelity/Surety Bond

*Fax:

Commercial Auto: Cargo / Freight:( Inland/Ocean Marine)

Heavy Equipment

Web Site Address:

Umbrella Liability: Professional Liability :

Other - Please specify or describe:

*Email:

*Send QuickQuote By : Email Fax Both

Current Insurance Carriers Name :

Policy Number

Expiration Date:

OccurrenceClaims Made

If Claim Made Provide Retroactive Date:

Please send copy to : edhemhill@hemphillinsuranceagency.com or Fax (936) 448-1013

*Business Address:

Address:

City:

State: Zip :

County:

Mailing Address: Same as Mailing Address
Address:

City :

State: Zip:

County :

Business Information:

Years in Business:

Total # Employees:

Employees : # Full Time: # Part Time:

Approx. Annual Gross Sales / Revenue $

Approx. Annual Payroll $

Business Owners , Partners ,or Officers

Premium Calculation Wage Limitations Applies To

Wages Included In Premium Calculation For ARTISAN Contractors

Provide Name Of Individual Owner or Partners

1. 2. 3. 4. 5.

$31,900- FLAT Annual Payroll (effective 12.01.84).

Automatically covered.

Provide Name Of LLC Members

1. 2. 3. 4. 5.

$31,900- FLAT Annual Payroll (effective 12.01.84).

Automatically covered.

Corporations

Provide Name Of Corporate Each Officer:

1. 2. 3. 4. 5.

$31,900- FLAT Annual Payroll (effective 12.01.84).

Automatically covered.

General Liability Coverage Limits Requested: Select Policy Type: Occurrence Claims Made
*General Liability Limit $ Per OccurrenceComb.Single Limit	Limit Per Each Occurrence Aggregate Limit All Claims	Product or Complete Operations Coverage $
* Medical Expense (No Fault) $		Personal & Advertising Injury $
* Deductible $ Per Claim Per Occurrence		Employee Benefits Liability $
*Fire Legal Liability $		Garage keeps Coverage $
Host Liquor or Liquor Liability $		Hired or Non-Owned Auto Liability $
Does you business currently have Professional Liability Insurance Coverage?YesNo If " Yes" Provide Insurers Name Policy # Effective Date

Location / Occupancy Information:

Location	Interest	Year Built	% Of Bldg .Occupied	Square Feet For Bldg or Office
	Owner Tenant				Check Here If You Have More Than 1 Location We will be contacting you by telephone or email to get additional location information
Location	Click To View Building Construction Type	Year Building Constructed	Number Stories	Distance To Fire Hydrant	Distance To Fire Station	Inside City Limits
						Yeno

Location	Fire Alarm Type	Does the business have a Fire Alarm Certificate?	Number Of Employees At This Location	Ownership - Mortgaged ?	Annual Rental Revenues (If applicable)
		YeNo			$
Does anyone permanently reside at any location ? YeNo If "Yes" List Locations
Location	Burglar Alarm Type	Does the business have a Burglar Alarm Certificate?	Number Of Basement Levels	Does building have fire sprinklers?	If sprinklers what % of building has sprinklers?	Square Footage Occupied By Your Business
		Yes No		Yes No	%	Sq Ft
Normal number of hours per day your business operations
Location	Indicate by checking the appropriate box below if any of the safety/security measures listed have been implemented :
	Exterior Light Front/Back Exterior Doors 2Cylinder Dead-Bolt Doors Wire Mesh/Bars Guard DogGuardVideoSmoke DetectorHoldup AlarmSafe
What is the maximum amount of cash money left at any location overnight ? $

Loss History Information:

Our Insurance Company Underwriters May Require Prior Carrier Generated Loss History Reports For Last 5 Years Prior To Binding Coverage.

*Has your business had any losses or filed a workers compensation claim in the last five years? YesNo

If "Yes" Please Briefly Provide Details ( amount paid / carrier / policy # / date of injury / nature of accident / injury sustained) or

Send Us Your Prior Insurers Valued Loss Runs For The Past 5 Years to: edhemphill@hemphillinsuranceagency.com or fax (936) 448-1013.

1. 2. 3. 4. 5.

Additional Comments/Remarks You Wish Us To Consider While Preparing Your Quote:

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or current policy revisions you must receive a written confirmation for any new or change in coverage from our agency staff.

Submitting Agent/ Producer - Name: Tel: Email:


#	Name	Description	Fillable Click
1.	ACORD 125	Commercial General Insurance Application
2.	ACORD 126	Commercial General Liability Section
Download All Application Forms To Your System - Complete Each Fillable Application - Print Send To : Email edhemphill@hemphillinsuranceagency.com or Fax (936) 448-1013

General Liability Insurance Coverage

Insurance Service Office (ISO) SAMPLE Policy Forms

Note: These Are Sample Policy Forms That Represent Insurance Industry Standardized Commercial Lines Policies.

Coverage proposals presented to you by our Agency may differ; as each insurer represented may offer modified coverage by endorsement or have filed it's own unique policy forms with the Texas Department Of Insurance. Please carefully read any carrier prepared proposal presented to you and where necessary request a copy of each insurance company policy form presented; so that you may compare any differences in coverage offered.

Commercial Comprehensive General Liability - ISO - Occurrence Policy Form # CG 00 01 12 07

Commercial Comprehensive General Liability - ISO - Claims Made Policy Form # CG DS 10 10 01

Overview

Every business also faces exposure to liability losses. A business may become legally liable (i.e., responsible for payment) for bodily injury suffered by another person or persons, or for damage to or destruction of the property of others. This liability may be the result of

! A court decision (as in a lawsuit charging negligence).

! Violation of contract provisions (a contract that makes one party responsible for certain kinds of losses).

Public Liability

A business may be held liable for injuries or other losses suffered by a member of the general public as the result of the firm's (or its employees') negligence or fault. Examples include

! A customer in a firm's building trips on a broken step.

! A defective product causes injury to its user.

! Improper installation of a product causes injury to a customer.

! A tenant is held responsible for a third-party injury occurring on the rented property, due to a clause he or she signed agreeing to such responsibility.

Your daily paper will provide dozens of other examples. A firm that is found legally liable for harming a third party must pay damages to compensate the injured party. Sometimes the court also imposes punitive damages and, in cases involving violation of statutes designed to protect the community, the court may levy fines in order to discourage future violations.