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General Liability Insurance


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Name & Address of Business (please submit seperate forms for each location)
Required
ZIP / Postal Code
Required
How lond have you been in business?
Required
GL Effective Dates
Optional
Auto Effective Dates
Optional
Work Comp Effective Dates
Optional
Type of Business
Required
If business is a Corporation, please provide Corporation Name
Optional
DBA?
Optional
First Name
Required
Last Name
Required
Primary Phone Number
Required
Fax Number
Optional
E-Mail Address
Required
F.E.I.N. Number
Optional
License Number
Optional
How many full-time employees?
Required
How many part-time employees?
Required
Type of Alarm
Required
Roof Type
Required
Annual payroll figures broken out by classification codes
(Please list all Class Codes with payroll. If you don't know Code, give description)
Code or Description
Required
Annual Payroll and #F/P
Required
Code or Description
Optional
Annual Payroll and #F/P
Optional
Code or Description
Optional
Annual Payroll and #F/P
Optional
Code or Description
Optional
Annual Payroll and #F/P
Optional
Code or Description
Optional
Annual Payroll and #F/P
Optional
Officers and/or Owners
Name / Title
Required
% of Ownership (must equal 100%)
Required
Included or Excluded
Required
Name / Title
Optional
% of Ownership (must equal 100%)
Optional
Included or Excluded
Optional
Do you provide Group Medical to Full-Time Employees?
Required

Do you provide Union Operation?
Required

What Union?
Optional
Policy Details
Year Built
Optional
# of Locations
Required
# of Buildings
Required
# of Stories
Required
Fire Sprinklers in Building
Required

Betterments and Improvements?
Required
Total Building Square Footage
Required
Public Square Footage
Required
Building Amount
Required
Contents Amount
In Office and Shop
Required
On Trucks
Required
Liability Limit
Required
Location Deductible
Required
Franchise
Required

Total Receipts
Required
Receipts: Estimated Total
Current Policy year?
Required
Subcontracted
Required
Percentage of total?
Required
Receipts for next 12 months?
Required
Subcontracted Percentage
Required
Types of Subcontracted work done
Required
Please send 4 years current valued Loss Runs to Vicki@rickrussoinsurance.com
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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