Shipman Insurance Agency - General Liability Quote Form

Company:

*First Name:

*Last Name:

*Email:

*Phone:

Contact Preference:

Address Line 1:

Address Line 2:

City:

State/Province:

ZIP/Postal Code:

Country:

Join Mailing List?

Please add me to your mailing list.

Your Web Site:

Fax:

New Venture:

Yes No

Cancelled or Non-renewed:

Yes No

Prior Carriers Name:

Any Losses Within The Last 3 Years:

Please state date and how much the loss was.

Number Of Employees And Amount Of Payroll:

Please exclude amount of owners payroll.

Gross Sales Amount:

Square Footage of Business:

Number of Officers and Partners:

Are Certificates Required From Your Sub-contractors:

What Percentage Of Operations Are Sub-contracted:

Number of Additional Insureds:

Number of Waivers of Subrogation Needed:

Please Enter One Limit for Each Coverage Listed:

Products Completed & Operations Aggregate:$100,000, 500,000, 1,000,000 or 2,000,000
Personal Advertising Injury: $100,000, 500,000, 1,000,000.
Each Occurrence: $100,000, 500,000, 1,000,000.
Fire Damage Legal: $50,000, 100,000.
Medical Expense: $5,000, 10,000

Please use Initials for Coverage Limits and dollar amount.

Submit Your Message:

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