Business General Liability Form - Alexander & Strunk Insurance

General Liability Quote Form Please fill out as much information as possible. If you have any questions about this form or filing a claim, please contact us.
BUSINESS INFORMATION
Name of Business:
Contact person:
All locations of business:
Type of business:
Preferred method of contact:
E-mail:
Telephone:
Fax:
Tax Identification Number:
COVERAGES REQUESTED
Premises Liability:
Products Liability:
Medical Payments:
ABOUT YOUR BUSINESS
Annual Sales:
Annual Payroll:
Number of full time employees:
Number of part-time employees:
Number of additional insureds:
Number of locations:
Do you have any overseas locations?:
If so, please provide their addresses.
CLAIMS HISTORY FOR 3 YEARS
Please list all claims within the last three years.


Submitting an insurance quotation request to Alexander & Strunk Insurance does not constitute a binding confirmation of new or altered insurance coverage. Verbal and/or written confirmation must be obtained from Alexander & Strunk Insurance to confirm binding or altering coverage.

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