General Liability Quote - Insurance Service Center

Business Information

Name*

First Last

Email*

Business Name

Address

Street Address City State ZIP Code

We only insure Kentucky and Tennessee

Phone

Fax

Business Structure

Fed Tax ID#

Business Type

Industry

Describe your Business

Number of Full Time Employees

Number of Part Time Employees

Estimated Annual Payroll

Estimated Annual Gross Receipts

Estimated Annual Sub Out

Number of Locations

Years in Business

Current Carrier Name

Policy Expiration

Premium Amount

Coverage Description

Liability Limit

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Number of Losses Claimed

Description of Loss	Date of Loss	Amount of Loss

Agent Name (Optional)

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