General Liability Insurance

Name & Address of Business (please submit seperate forms for each location) Required Name & Address of Business (please submit seperate forms for each location) is required.
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
How lond have you been in business? Required How lond have you been in business? is required.
GL Effective Dates Optional
Auto Effective Dates Optional
Work Comp Effective Dates Optional
Type of Business Required Type of Business is required.	select Sole Proprietor Partnership Corporation L.L.C.
If business is a Corporation, please provide Corporation Name Optional
DBA? Optional
First Name Required Input Required
Last Name Required Input Required
Primary Phone Number Required Input Required Please enter a valid phone number
Fax Number Optional
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
F.E.I.N. Number Optional
License Number Optional
How many full-time employees? Required How many full-time employees? is required.
How many part-time employees? Required How many part-time employees? is required.
Type of Alarm Required Type of Alarm is required.
Roof Type Required Roof Type is 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 Code or Description is required.
Annual Payroll and #F/P Required Annual Payroll and #F/P is 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 Name / Title is required.
% of Ownership (must equal 100%) Required % of Ownership (must equal 100%) is required.
Included or Excluded Required Included or Excluded is required.	select Included Excluded
Name / Title Optional
% of Ownership (must equal 100%) Optional
Included or Excluded Optional	select Included Excluded
Do you provide Group Medical to Full-Time Employees? Required Do you provide Group Medical is Required	Yes No
Do you provide Union Operation? Required Do you provide Union Operation? is required.	Yes No
What Union? Optional
Policy Details
Year Built Optional	select 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
# of Locations Required # of Locations is required.
# of Buildings Required # of Buildings is required.
# of Stories Required # of Stories is required.
Fire Sprinklers in Building Required Fire Sprinklers in Building is required.	Yes No
Betterments and Improvements? Required Betterments and Improvements? is required.
Total Building Square Footage Required Total Building Square Footage is required.
Public Square Footage Required Public Square Footage is required.
Building Amount Required Building Amount is required.
Contents Amount
In Office and Shop Required In Office and Shop is required.
On Trucks Required On Trucks is required.
Liability Limit Required Liability Limit is required.
Location Deductible Required Location Deductible is required.
Franchise Required Franchise is required.	Yes No
Total Receipts Required Total Receipts is required.
Receipts: Estimated Total
Current Policy year? Required Current Policy year? is required.
Subcontracted Required Subcontracted is required.
Percentage of total? Required Percentage of total? is required.
Receipts for next 12 months? Required Receipts for next 12 months? is required.
Subcontracted Percentage Required Subcontracted Percentage is required.
Types of Subcontracted work done Required Types of Subcontracted work done is required.
Please send 4 years current valued Loss Runs to Vicki@rickrussoinsurance.com
Enter Validation Code Required

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