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General Business Liability

CALIFORNIA, ARIZONA, NEVADA, ONLY

Corporation       Individual       Partnership        Other

Name *
Email Address *
Company
Type of Business: (Auto Service, Printing, Stationary, etc)
Mailing Address
Subject Address
City
County
State
Zip Code
Phone Number
Fax Number
Contact Person
General Liability Limits
Exp. Date Liability
Number of Employees /Full Time   /Part Time
Building Value (if owned)
Business Equipment & Inventory
Company Owned Vehicles Number    Overall Value
Business Losses last 3 years (Actual Loss Sustained)
Gross Sales
Payroll
Current Carrier
Policy Number   Exp. Date
Premium
   
Specify Losses in the Last 3 Years