Commercial General Liability Insurance Quote Request 

Legal Name Of Business
Name Of Insured/Owner
Exact Location address
Additional Locations
Exact Nature of Business
Phone Number
Contact Person
Amount of Personal Property Coverage
Copy of Current Policy If Applicable
Loss Runs(Claims) for last 3 years
Number of Years in Business
Annual Payroll
Annual or Projected Gross Sales
Year the building was constructed
The sq.ft. of building
The sq.ft. of occupied space
a. Construction Type
b. Sprinkler System
c. Alarm System
d. Co. Certificate Number of Alarm System
e. Number of Stories
Liability Coverage Limit
Additional Interests(if yes,who)
Type of Business on the Right, Left and Rear

EXPLAIN ALL "YES" RESPONSES(For past or present operations)	Check, If YES
1. Any medical facilities provided or medical professionals employed or contacted?
2. Any exposure to radioactive/nuclear materials
3. Do/have past, present or discontinued operations involved(d) storing, treating, discharging, applying, disposing or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks etc.)
4. Any operations sold, acquired or discontinued in last 5 years?
5. Machinery or equipment loaned or rented to others?
6. Any watercraft, docks, floats owned, hired or leased?
7. Any parking facilities owned/rented?
8. Is a fee charged for parking?
9. Recreation facilities provided?
10. Is there a swimming pool on the premises?
11. Sporting or social events sponsored?
12. Any structural alterations contemplated?
13. Any demolition exposure contemplated?
14. Has applicant been active in or is currently active in joint ventures?
15. Do you lease employees to or from other employers?
16. Is there a labor interchange with any other business or subsidiaries?
17. Are day care facilities operated or controlled?
18. Have any crimes occured or been attempted on your premises within the last 3 years?
19. Is there a formal written safety and security policy in effect?
20. Does the businesses' promotional literature make any representations about the safety or security of premises?
Remarks:

Established 1985
(Lic. # 0697055)

Phone:  1-800-257-7718  /  (408) 997-7718

Fax:   1-800-246-0007  /  (408) 997-7890

Email: business@jeewanjee.com