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) *

ZIP / Postal Code *

How lond have you been in business? *

GL Effective Dates

Auto Effective Dates

Work Comp Effective Dates

Type of Business *

If business is a Corporation, please provide Corporation Name

DBA?

First Name *

Last Name *

Primary Phone Number *

Fax Number

E-Mail Address *

F.E.I.N. Number

License Number

How many full-time employees? *

How many part-time employees? *

Type of Alarm *

Roof Type *

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 *

Annual Payroll and #F/P *

Code or Description

Annual Payroll and #F/P

Code or Description

Annual Payroll and #F/P

Code or Description

Annual Payroll and #F/P

Code or Description

Annual Payroll and #F/P

Officers and/or Owners

Name / Title *

% of Ownership (must equal 100%) *

Included or Excluded *

Name / Title

% of Ownership (must equal 100%)

Included or Excluded

Do you provide Group Medical to Full-Time Employees? *

Yes
No

Do you provide Union Operation? *

Yes
No

What Union?

Policy Details

Year Built

# of Locations *

# of Buildings *

# of Stories *

Fire Sprinklers in Building *

Yes
No

Betterments and Improvements? *

Total Building Square Footage *

Public Square Footage *

Building Amount *

Contents Amount

In Office and Shop *

On Trucks *

Liability Limit *

Location Deductible *

Franchise *

Yes
No

Total Receipts *

Receipts: Estimated Total

Current Policy year? *

Subcontracted *

Percentage of total? *

Receipts for next 12 months? *

Subcontracted Percentage *

Types of Subcontracted work done *

Please send 4 years current valued Loss Runs to Vicki@rickrussoinsurance.com

Submission Validation

Required

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.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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951 Reserve Drive Suite 160 | Roseville, CA 95678 | Office: 916.791.1901 | Toll-Free: 800.281.7873