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                         Home | About Us | Contact Us | Applications & Forms General Liability Insurance With Several Leading Insurance Companies

To Get A Quick-Quote Complete The Below Underwriting & Rating Information Form




Please fill out as much information as possible.

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

  Commercial / Business General Liability Insurance Quote Request

(* 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 That You Want Us To  Quote:

*Contact Phone:

 Cell # 

Business Owners Policy     : Package Policy That Combines

Building / Contents / Liability

Into A Single Policy


Flood Insurance :                     

Workers Comp:                           Fidelity/Surety Bond                      


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

Web Site Address:


Umbrella Liability:                        Professional Liability :

Other - Please specify or describe:



*Send QuickQuote By : Email Fax Both



Current Insurance Carriers Name :  

Policy Number

Expiration Date:  

OccurrenceClaims Made

If Claim Made Provide Retroactive Date:

Please send copy to : or Fax (936) 448-1013

 *Business Address:          



 State: Zip :


Mailing Address:          Same as Mailing 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

$31,900- FLAT Annual Payroll (effective 12.01.84).

Automatically covered. 

Provide Name Of LLC Members

$31,900- FLAT Annual Payroll (effective 12.01.84).

Automatically covered. 



Provide Name Of Corporate Each Officer:

$31,900- FLAT Annual Payroll (effective 12.01.84).

Automatically covered. 


General Liability Coverage Limits Requested:  Need help with selecting coverage limits or understanding coverages offered call 1-800-361-8734 !      Select Policy Type:  Occurrence Claims Made

 *General Liability Limit $

Per OccurrenceComb.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


Location / Occupancy Information: Need help with completeing the rating information section call 1-800-361-8734 !


Year Built  % Of Bldg .Occupied Square Feet For Bldg or Office    
Owner Tenant Check Here If You Have More Than 1 Location

We will be contacting you by telephone or email to get additional location information

Location            Click To View

Building Construction Type

Year      Building      Constructed Number Stories Distance To                                         Fire Hydrant Distance To                Fire Station Inside City Limits

Fire Alarm Type

Does the business        have a Fire Alarm Certificate? Number Of  Employees At This Location    Ownership - Mortgaged ?

Annual Rental Revenues                     (If applicable)

YeNo $  
Does anyone permanently reside at any location ? YeNo If "Yes" List Locations  

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: or fax (936) 448-1013.


          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.


Submitting Agent/ Producer  - Name: Tel: Email:











Fillable Click



Commercial General Insurance Application

  PDF Fillable



Commercial General Liability Section

  PDF Fillable

Download All Application Forms To Your System - Complete Each Fillable Application - Print

 Send To : Email or Fax (936) 448-1013

General Liability Insurance Coverage

Insurance Service Office (ISO) SAMPLE Policy Forms

Note: These Are Sample Policy Forms That Represent Insurance Industry Standardized Commercial Lines Policies.

Coverage proposals presented to you by our Agency may differ; as each insurer represented may offer modified coverage by endorsement or have filed it's own unique policy forms with the Texas Department Of Insurance. Please carefully read any carrier prepared proposal presented to you and where necessary request a copy of each insurance company policy form presented; so that you may compare any differences in coverage offered.


Commercial Comprehensive General Liability - ISO - Occurrence Policy Form # CG 00 01 12 07
 Commercial Comprehensive General Liability - ISO - Claims Made Policy Form # CG DS 10 10 01


Every business also faces exposure to liability losses. A business may become legally liable (i.e., responsible for payment) for bodily injury suffered by another person or persons, or for damage to or destruction of the property of others. This liability may be the result of 

          !         A court decision (as in a lawsuit charging negligence).

          !         Violation of contract provisions (a contract that makes one party responsible for certain kinds of losses).

 Public Liability 

A business may be held liable for injuries or other losses suffered by a member of the general public as the result of the firm's (or its employees') negligence or fault. Examples include

          !         A customer in a firm's building trips on a broken step.

          !         A defective product causes injury to its user.

          !         Improper installation of a product causes injury to a customer.

          !         A tenant is held responsible for a third-party injury occurring on the rented property, due to a clause he or she signed agreeing to such responsibility. 

Your daily paper will provide dozens of other examples. A firm that is found legally liable for harming a third party must pay damages to compensate the injured party. Sometimes the court also imposes punitive damages and, in cases involving violation of statutes designed to protect the community, the court may levy fines in order to discourage future violations.

Regardless of who wins or loses a law suit, litigation is time consuming and expensive. No matter how ridiculous or unfounded the suit may be, productive business hours are lost, lawyers must be retained and paid and other related costs must be met while the suit is being contested. 

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