BUSINESS OWNERS PROGRAM
Michigan General Liability Quote
Request
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No coverage is bound until you are contacted
by one of our representatives.
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1
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Contact
Information |
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Contact Name: |
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Name of Business |
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Address: |
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Address 2: |
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City - St - Zip: |
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Phone Number: |
FAX
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E-Mail Address: |
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2
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Desired Limits: (Each Occurrence /
General Aggregate) (other limits may
be available upon request)
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3
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What percentage,
if any, of gross receipts/revenues
is derived from service and/or
installation of products?
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4
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\What
percentage, if any, of gross
receipts/revenues is derived from
the rental of any equipment?
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5
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Please indicate whether any of the
following optional coverages are
desired: (the limits provided will
be the same as the limits chosen in
number 1 above). |
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Employee Benefits Liability
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YES
NO
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Liquor Liability |
YES
NO
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If yes, please provide annual Liquor
Receipts $ |
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Hired and Non-owned Auto Liability
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YES
NO
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Stop Gap Liability (ND, OH, WA, WV
and WY only) |
YES
NO
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Limited International General
Liability Extension Endorsement
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YES
NO
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6
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Please indicate whether any of the
following exclusions are desired. |
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a) General Liability Enhancement
Endorsement (adds additional
insureds and other broadening
coverages). |
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YES
NO
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b) General Liability Extended
Enhancement Endorsement (adds
extended property damage and other
broadening coverages). |
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YES
NO
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Wholesale Applicants ONLY
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7
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Are all goods manufactured
domestically or by a company with a
location in the US?
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YES
NO
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AIf no, is Imported Products
Liability Coverage desired? |
YES
NO
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If Imported
Products Liability Coverage is
desired, what are the gross annual
sales for foreign manufactured
products? $
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8
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Do you do any repackaging,
re-labeling, repair or
re-manufacturing of products? |
YES
NO
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