Community Insurance Advisors :: General Liability Insurance

Section I - Client Business / Information

Name: *

Phone: *

Email: *

Confirm Email: *

Mailing Address *

Location Address: *

Business Description: *

Business Contact: *

Business Phone: *

In Business Since: *

Type of Business: *

Any exposure in other states:

*If yes, which States(s):

Average employee longevity: *

What other types of policies do you have with your current carrier:

Following forms are optional, Please fill in if you would like to provide more information.

Section II - Property Liability

Construction Type:

Year Built:

Square Footage:

# of Stories:

Sprinklers:

Distance to Fire Hydrant:

Alarms:

Year Electrical Updated:

Year Roof Updated:

Year Plumbing Updated:

Building deductible:

Years at location:

Is there a safe on premises?

Yest

Loss of income:

Contents:

Signs:

# Full-time Employees:

# Part-time Employees:

Annual Payroll:

Section III - Liability

Umbrella Coverage:

Worker's Compensation:

Number of Autos:

Hired/Non-owned:

Auto #1 Year:

Auto #1 Make:

Auto #1 Model:

Auto #2 Year:

Auto #2 Make:

Auto #2 Model:

Auto #3 Year:

Auto #3 Make:

Auto #3 Model:

Auto #4 Year:

Auto #4 Make:

Auto #4 Model:

Auto #5 Year:

Auto #5 Make:

Auto #5 Model:

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Community Insurance Advisors - A Different Way of Doing Insurance
P:972-758-9300 | F:972-758-9355

General Liability Insurance

General Liability Insurance Application

Section I - Client Business / Information

Section II - Property Liability

Section III - Liability

TDI License Numbers

Community Insurance Advisors - A Different Way of Doing InsuranceP:972-758-9300 | F:972-758-9355

General Liability Insurance

General Liability Insurance Application

Section I - Client Business / Information

Section II - Property Liability

Section III - Liability

TDI License Numbers

Community Insurance Advisors - A Different Way of Doing Insurance
P:972-758-9300 | F:972-758-9355