ABOUT US
CONTACT US
BLOG
X
Personal
Home
Pet
Auto
Life
Business
Commercial Auto
Workers Compensation
Trucking
X
General liability Application
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Phone
*
Email
*
Preferred Method of Contact
Call
Text
Email
Business Information
Legal Business Name
*
DBA (if applicable)
FEIN
Business Structure
Sole Proprietor
Partnership
LLC
Corporation
Business Address
*
Years in Business
*
Operations & Business Details
Description of Business Operations
*
Primary Industry / Business Type
Annual Gross Revenue ($)
*
Number of Employees
*
(full time/part time)
Do you perform work at client locations?
Yes
No
Do you subcontract any work?
*
Yes
No
If yes, do subcontractors carry their own insurance?
*
Yes
No
Do you require certificates of insurance from subcontractors?
*
Yes
No
Coverage Information
Coverage Type Requested:
*
General Liability
Professional Liability
Product Liability
Contractor Liability
Event Liability
Coverage insurance subcontractors
Desired Coverage Amount?
*
Enter the desired coverage amount
Desired Policy Effective Date
*
Property & Risk Exposure (If Applicable)
Do you own or lease commercial property?
*
Own
Lease/Rent
Total Square Footage
Number of Locations
Any warehouse, storage, or manufacturing operations?
Yes
No
Any hazardous materials used or stored?
Yes
No
Claims & Insurance History
Current Insurance Carrier (if any)
Policy Expiration Date
Any workers comp claims in the past 5 years?
*
Yes
No
If yes, please describe
File Upload
Drag & Drop Files,
Choose Files to Upload
Upload policy declarations or certificate of insurance
Consent
I agree to be contacted by Merrill Insurance Agency, Inc. regarding my quote request.
Submit
