15001Walden Rd., Suite 215C
Montgomery, TX 77356

1-866-TEXAS-45
(1-866-839-2745)

Texas Commercial General Liability Insurance for Texas Based Businesses

Commercial General Liability Insurance

Commercial Insurance

Please provide the following information:
Complete the following information if you would like to obtain a commercial Insurance quote. Remember, this is not an application, one will be sent to you if coverage is requested.
All information provided on this information sheet is confidential and will be used solely for the purpose of quoting your commercial insurance.

Personal Information

What is your name?

Last

First

Middle

What is your business name?

Business Name

County Information

County

What is your address?

Street

City

State

Zip

What is your telephone number?

Home

Business

What is your fax number?

Fax

What is your email address?

Email

Confirm your email address?

Email

Underwriting Information

What is the nature of your business?

*** Required - Business Description

Nature of Business

Is the business a corporation, partnership or sole proprietorship?

Corporation
Partnership
Sole Proprietorship

How many owners?

Number of Owners

How many employees?

Number of Employees

What is the payroll amount of the owners?

Required

Payroll of Owners

What is the payroll amount of the employees?

Required

Payroll of Employees

What is the total annual gross?

Required

Total Annual Gross Receipts

What is the business license number?

Business License Number

What is the license type?

License Type

Years of experience in this business?

Required

Years of Experience

How many years have you operated under your current business name?

Years Operated Under Current Name

Have you used any other business names during the past 5 years?

Other Business Names

Yes No

Is this business open 24 hours a day

Open 24 Hours

Yes No

Please describe the nature of your business and ANY unusual exposures.

Unusual Exposures

Building & Property Information

Year built?

Year built

What is the total square footage of the building your business is in?

Total Square Footage of Business Building

What is the total square footage of your business only?

Total Square Footage of Business Only

What is the square footage of the customer area only?

Square Footage of Customer Area

How many stories is it?

Stories

If it's two stories, what is the ground floor square footage?

Ground Floor Square Footage

Claims Information

Where there any losses or claims in the last 5 years?

Losses - Claims

Yes No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

What is the current insurance company?

How much are you paying now?

Amount Current Coverage

What is the liability limit requested?

Liability Limit

What is the building limit requested?

If no coverage is required for your building - Please type in N/A or 0

Building Limit

Do you require Coverage for the building?

Yes/No

What is the building deductible requested?

Building Deductible

What is the business personal property (contents) limit requested?

Business Personal Property

Do you require Coverage for the business personal property?

Yes/No

What is the contents deductible requested?

Contents Deductible

What is the loss of income requested?

Loss of Income Coverage

Are there any questions, comments or additional coverage required?

Questions, Comments or Additional Coverage

When is the best time to contact you.

Morning
Afternoon
Evening
Anytime

I currently have insurance
Yes No