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	Enter the Validation Code from above.

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