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GET A QUOTE FOR COMMERCIAL GENERAL LIABILITY

Effective Date of Policy Desired(Required)

Detailed Description (Operations) of Services Offered(Required)

Owner(s)

Name(Required)

First Last

Phone(Required)

Email(Required)

Mailing Address

Street Address Address Line 2 City State ZIP Code

Physical Address: (if different)

Street Address Address Line 2 City State ZIP Code

Years of Experience(Required)

Business Information

Full Name of Business(Required)

Business Type(Required)

Business Start Date(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Physical Address: (if different)(Required)

Street Address Address Line 2 City State ZIP Code

Do you have current coverage in place?(Required)

Yes

If so, who is the insurance company(s)(Required)

How many years with this company?(Required)

Have any claims been filed in the last 5 years?(Required)

Commercial General Liability

Estimated Gross Annual Sales for the next 12 months(Required)

Number of Owners(Required)

# Of Employees - Full time(Required)

# Of Employees - Part time(Required)

Annual Payroll for Employees (excluding owner(s)(Required)

FOR CONTRACTORS ONLY

% Of Residential vs % of Commercial

% Of Exterior vs % of Interior

Do you use Sub - Contractors?(Required)

Yes

If so, what is the percentage?(Required)

What jobs/duties are performed by sub - contractors

What percentage of your sub - contractors are insured?

If sub - contractors are insured, do they carry coverages or limits less than yours?(Required)

Yes

Annual amount paid to sub - contractors including materials - Insured

Annual amount paid to sub - contractors including materials - Uninsured

Additional comment, if any

Application signature(Required)

Date(Required)

Applicant’s Title(Required)

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QUOTE

GET A QUOTE FOR COMMERCIAL GENERAL LIABILITY

Owner(s)

Business Information

Commercial General Liability

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WE OFFER

ABOUT US

GET A QUOTE

CONTACT

KEEP UP WITH LEH INSURANCE