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  General Liability Insurance Quote
Full Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Website Address:
Day Telephone:  
Eve Telephone:  
Fax:  
 
 Questions
Desired Limits: (Each Occurrence / General Aggregate)
(other limits may be available upon request)
$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000
What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products? %
What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment? %
 
 Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen above)
Employee Benefits Liability:     No
Liquor Liability: Yes    No
If yes, please provide annual Liquor Receipts $
Hired and Non-owned Auto Liability: Yes    No
Stop Gap Liability (if applicable) : Yes   No
Limited International General Liability Extension Endorsement: Yes No
 
 Please indicate whether any of the following exclusions are desired.
a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages): Yes No
b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages). Yes   No
 
 Wholesale Applicants ONLY

Are all goods manufactured domestically or by a company with a location in the US?

Yes   No

If no, is Imported Products Liability Coverage desired? Yes   No
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products? $

Do you do any repackaging, re-labeling, repair or re-manufacturing of products?

Yes   No

 
 Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.

We will not distribute information to other parties other than for insurance underwriting purposes.

By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

 

YES! I Agree - By checking this box, you agree to release us from any liability should this information be accidentally viewed by others and you specifically agree that you are permitting any records to be run and reviewed in order to provide you with the best quotation including but not limited to accident loss history, motor vehicle record and credit.

 

   
 

 

 

(p) (828) 258-8030 ∙ (f) (828) 258-8030
(e) tony_johnson_agency@nationwide.com