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General Liability Quote Form
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Your Name:
BUSINESS Name:
Mailing Address:
City:
State: (Must be Iowa)
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Social Sec. or Employer ID#:
 
Limit of Liability
Coverage Requested?		 $300,000
$500,000
$1 Million
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
 
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
 
Number of Active Owners:
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $
Annual Gross Sales: $
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

 
Comments/Remarks:
 
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E-Mail: paul@goodhuenolte.com   |   More About our Agency's Services
PO Box 1000, 100 Highway 5    Carlisle, IA 50047   (Click for Map)    |    Phone: 515-989-3200
Fax: 515-989-5255    |   Privacy Notice/Copyright Info.      |    © 2006 Insurance-Web-Sales
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