Commercial General Liability Insurance Quote Request

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Online Commercial General Liability Insurance Quote Request Form

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

Named Insured:

General Information:

* Business Name

Type of Business :

*Contract - Full Name:

Describe Operations :

* Title / Position:

Business Model:

* Employers Federal Tax Id # (FEIN)

Select Any Other Kinds Of Coverage Below That You Need Quoted:

*Contact Phone:

Cell #

Business Owners Policy : Package Policy That Combines

Building / Contents / Liability

Into A Single Policy

Flood Insurance :

Workers Comp: Fidelity/Surety Bond

*Fax:

Commercial Auto: Cargo / Freight:( Inland/Ocean Marine)

Heavy Equipment

Web Site Address:

Umbrella Liability: Professional Liability :

Other - Please specify or describe:

*Email:

*Send Quick Quote By : Email Fax Both

Current Insurance Carriers Name :

Policy Number

Expiration Date:

OccurrenceClaims Made

If Claim Made Provide Retroactive Date:

Please send copy to : edhemhill@hemphillinsuranceagency.com or Fax (936) 448-1013

*Business Address:

Address:

City:

State: Zip :

County:

Mailing Address: Same as Mailing Address
Address:

City :

State: Zip:

County :

Business Information:

Years in Business:

Total # Employees:

Employees : # Full Time: # Part Time:

Approx. Annual Gross Sales / Revenue $

Approx. Annual Payroll $

Business Owners , Partners ,or Officers Premium Calculation Wage Limitations Applies To	Wages Included In Premium Calculation For ARTISAN Contractors
Provide Name Of Individual Owner or Partners 1. 2. 3. 4. 5.	$31,900- FLAT Annual Payroll (effective 12.01.84). Automatically covered.
Provide Name Of LLC Members 1. 2. 3. 4. 5.	$31,900- FLAT Annual Payroll (effective 12.01.84). Automatically covered.
Corporations Provide Name Of Corporate Each Officer: 1. 2. 3. 4. 5.	$31,900- FLAT Annual Payroll (effective 12.01.84). Automatically covered.

General Liability Coverage Limits Requested: Select Policy Type: Occurrence Claims Made
*General Liability Limit $ Per Occurrence Combined Single Limit	Limit Per Each Occurrence Aggregate Limit All Claims	Product or Complete Operations Coverage $
* Medical Expense (No Fault) $		Personal & Advertising Injury $
* Deductible $ Per Claim Per Occurrence		Employee Benefits Liability $
*Fire Legal Liability $		Garage keeps Coverage $
Host Liquor or Liquor Liability $		Hired or Non-Owned Auto Liability $
Does you business currently have Professional Liability Insurance Coverage?YesNo If " Yes" Provide Insurers Name Policy # Effective Date

Locations: Check Here If You Have More Than 1 Location ( We will be contacting you by telephone or email to get additional location information )

Location	Street	City	State	Zip Code	County	Bldg Square Feet	Number Of Employees

Interest	Owner Tenant	Year Built		% Occupied

Occupancy Information:

Location	Click To View Building Construction Type	Year Building Constructed	Number Stories	Distance To Fire Hydrant	Distance To Fire Station	Inside City Limits
						Yeno

Location	Fire Alarm Type	Does the business have a Fire Alarm Certificate?	Number Of Employees At This Location	Ownership - Mortgaged ?	Annual Rental Revenues (If applicable)	Percentage of Building Occupied
		YeNo			$	%
Does anyone permanently reside at any location ? YeNo If "Yes" List Locations
Location	Burglar Alarm Type	Does the business have a Burglar Alarm Certificate?	Number Of Basement Levels	Does building have fire sprinklers?	If sprinklers what % of building has sprinklers?	Square Footage Occupied By Your Business
		Yes No		Yes No	%	Sq Ft
Normal number of hours per day your business operations
Location	Indicate by checking the appropriate box below if any of the safety/security measures listed have been implemented :
	Exterior Light Front/Back Exterior Doors 2Cylinder Dead-Bolt Doors Wire Mesh/Bars Guard DogGuardVideoSmoke DetectorHoldup AlarmSafe
What is the maximum amount of cash money left at any location overnight ? $

Loss History Information:

Our Insurance Company Underwriters May Require Prior Carrier Generated Loss History Reports For Last 5 Years Prior To Binding Coverage.

*Has your business had any losses or filed a workers compensation claim in the last five years? YesNo

If "Yes" Please Briefly Provide Details ( amount paid / carrier / policy # / date of injury / nature of accident / injury sustained) or

Send Us Your Prior Insurers Valued Loss Runs For The Past 5 Years to: edhemphill@hemphillinsuranceagency.com or fax (936) 448-1013.

1. 2. 3. 4. 5.

Underwriting Questions & Information:

Please carefully review the questions and pre-selected answers below. Please make any corrections necessary so as to assure that each question presented herein has been correctly and truthfully answered to the best of your knowledge.

1.Is the applicant a subsidiary of another entity ?YesNo	14. Has applicant been active in or is currently active in joint ventures? YesNo
2.Does the applicant have any subsidiaries ? YesNo	15. Do you lease employees to or from other employers ? YesNo
3. Is a formal safety program in operation?YesNo Most Insurance Companies require any insured business owners to provide written proof at time of application and at each annual renewal that their firm maintains a written safety manual and documentation that the your firm conducts weekly employee safety meeting. Click Here To Get Affordable Safety Program	16. Is there a labor interchange with any other business or subsidiaries ? YesNo
4. Any exposure to flammables , explosives, chemicals ? YesNo	17. Are day care facilities operated or controlled ? Have any crimes occurred or been attempted on your premises within the last three (3) years ? YesNo
5. Any catastrophe exposure ? YesNo	18. Have any crimes occurred or been attempted on your premises within the last three (3) years ? YesNo
6. Any other insurance with this company or being submitted ? YesNo	19. Is there a formal, written safety and security policy in effect ? YesNo Most Insurance Companies require any insured business owners to provide written proof at time of application and at each annual renewal that their firm maintains a written safety manual and documentation that the your firm conducts weekly employee safety meeting. Click Here To Get An Affordable Safety Program For Your Business
7. Any policy or coverage declined, cancelled, or non-renewed during the prior 3 years? YesNo	20. Does the business promotional literature make any representations about safety or security of the premises ? YesNo
8. Any past losses or claims related to sexual abuse or molestation allegations, discrimination or negligent hiring ? YesNo	*" ARTISAN CONTRACTORS "* Complete Below Section If You Operate As A General Or Sub-Contractor In Construction or Tradesman Industry Check Here & Complete This Section
9. During past 5 yrs has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property ? YesNo	1. Does applicant draw plans, design, or specification for other ? YesNo
10. Any uncorrected fire code violations ? YesNo	2. Do any operations include blasting or utilize or store explosive material ? YesNo
11. Any tax liens, law suits, or bankruptcy within 5 years?YesNo	3. Do any operations include excavation, tunneling, underground work or earth moving ? YesNo
12. Has business been placed in a trust ? YesNo	4. Do your sub-contractors carry coverage or limits less than yours ? YesNo
13. Any foreign operations, foreign products distributed in USA, or US products sold/distributed in foreign countries ? YesNo	5. Are sub-contractors allowed to work without providing you with a certificate of insurance?YesNo
14. Any medical facilities provided or medical professionals employed or contracted ? YesNo	6. Does applicant lease equipment to other with or without operators ? YesNo
15. Any exposure to radioactive/nuclear materials? YesNo	Describe The Type Work Sub-contracted :
16. Do/Have past, present or discontinued operations involve storing, treating, discharging, applying, disposing, or transporting of hazardous material ? YesNo (e.g. landfills, wastes, fuel tanks, ect )	Subs Paid Annually % Work Sub # Full Time # Part Time
17. Any operations sold, acquired, or discontinued in last five (5) years ? YesNo
18. Machinery or equipment loaned or rented to others ? YesNo	Products/Completed Operations If You Firms Is Requesting Products or Completed Operations Coverage Check Here & Complete This Section
19. Any watercraft, docks, floats owned, hired or leased ? YesNo	1. Does applicant install, service, or demonstrate products ? Yes No
20. Any parking facilities owned/rented ? YesNo	2. Foreign products sold, distributed, used as components ? Yes No
21. Recreation facilities provided ? YesNo	3. Research and development conducted or new products planned ? Yes No
22. Is there a swimming pool on the premises ? YesNo	4. Guarantees, Warranties, Hold Harmless Agreements? Yes No If " Yes " Please explain in below remarks / comments section
24. Sporting or social events sponsored ? YesNo	5. Products related to Aircraft / Space Industry ? Yes No
24. Sporting or social events sponsored ? YesNo	6. Products recalled, discontinued, changed ? Yes N
25. Any structural alterations contemplated ? YesNo	7. Products of others sold or re-packaged under applicant name ? Yes N
25. Any structural alterations contemplated ? YesNo	8. Products under label of others ? Yes N
26. Any demolition exposure contemplated ? YesNo	9. Vendors Coverage Required ? Yes N
26. Any demolition exposure contemplated ? YesNo	10. Does any named insured sell to other named insured's ? Yes N

Comments/Remarks

If you answered " Yes " above questions - please indicate question # with details ?

Submitting Agent / Producer - Name: Tx License Number:
Agent's : Address: City: State: Zip Code:	Agent's: Telephone: Area Code Number Fax : Area Code Number Email:

Additional Comments/Remarks You Wish Us To Consider While Preparing Your Quote:

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. To confirm binding or current policy revisions you must receive a written confirmation for any new or change in coverage from our agency staff.

ACORD FILLABLE APPLICATIONS (These Are Insurance Industry Standardized Underwriting Forms Accepted By Virtually All Carriers )
#	Name	Description	Fillable Click
1.	ACORD 125	Commercial General Insurance Application
2.	ACORD 126	Commercial General Liability Section
Download All Application Forms To Your System - Complete Each Fillable Application - Print Send To : Email edhemphill@hemphillinsuranceagency.com or Fax (936) 448-1013