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

Yes
No

Do you provide Union Operation?

Required

Yes
No

What Union?

Optional

Policy Details

Year Built

Optional

# of Locations

Required

# of Buildings

Required

# of Stories

Required

Fire Sprinklers in Building

Required

Yes
No

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

Yes
No

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

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