General Liability Quote Insured NameAs it should appear on the policyMailing AddressLocation of RiskProposed Effective DateDescribe all business operations conducted.Does the applicant subcontract work?YesNoIf yes, state type.Subcontract TypeAre Certificates of Insurance required from all subcontractors?YesNoDuring the past 3 years has any company ever cancelled, declined, or refused to issue similar insurance to the applicant?YesNoIf yes, please explain.Explain cancelled, declined, or refused insurance.Estimated Gross ReceiptsUSDEstimated Employee PayrollUSDEstimated Sub-Contracted CostUSDHas the insured or applicant had prior coverage?YesNoIf yes, please complete the Prior Insurer information below (Year, Insurance Company, Policy #, and Premium).Has the insured or applicant had any prior claims or losses in the last 3 years?YesNoIf yes, please complete the Loss information below (Date of Loss, Loss Amount Paid, Loss Amount Reserved, and Description).Prior InsurerYearInsurance CompanyPolicy NumberPremiumLossDate of LossLoss Amount PaidUSDLoss Amount ReservedUSDDescription of Loss Send Message