General Liability Information Form

Legal Company Name (As filed with the state)

DBA Company Name

Company Type

Contact Name

Company Phone Number

Contact Mobile Phone Number

Company Address

Company Website

Company FEIN or Tax ID

NAICS or SIC Code

Year Business Founded

Requested Effective Date of Policy(s)

How Many Owners In The Business?

Description of Business

Revenue For Most Previous Fiscal Year

Forecasted Revenue For This Fiscal Year

# of Employees

Current Approximate Premium

# of Locations (Address for each including county and zip code)

# of Additional Interests (Name, Address and type of interest for each AI (Additional Insured, Co-Owner, Lienholder, Loss Payee, Mortgagee, Trustee, Owner, Other (Please describe in detail)) If more than 2 please email at sales@wordpress-816312-3363583.cloudwaysapps.com

Do You Have Employers’ Liability?

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