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Home > Business Commercial > General Liability Insurance
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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) *
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? *

Do you provide Union Operation? *

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

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 *

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
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