BUSINESS OWNERS PROGRAM
General Liabilty Quote Request
1
 Contact Information
Contact Name:
Name of Business
Address:
Address 2:
City - St - Zip:
Phone Number:       FAX
E-Mail Address:
2
 Desired Limits: (Each Occurrence / General Aggregate) (other limits may be available upon request)
$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000    
3
 What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?
4
 \What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?
5
 Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above).
  Employee Benefits Liability
YES NO
  Liquor Liability
YES NO
  If yes, please provide annual Liquor Receipts $
  Hired and Non-owned Auto Liability
YES NO
  Stop Gap Liability (ND, OH, WA, WV and WY only)
YES NO
  Limited International General Liability Extension Endorsement
YES NO
6

Please indicate whether any of the following exclusions are desired.
a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).
 
YES NO
b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).

YES NO
Wholesale Applicants ONLY
7
 Are all goods manufactured domestically or by a company with a location in the US?
YES NO
  AIf no, is Imported Products Liability Coverage desired?
YES NO
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products? $
8
 Do you do any repackaging, re-labeling, repair or re-manufacturing of products?
YES NO