General Liability Insurance Application
Business Information
Business Name
Type of Business
Years in Business
Business Structure
Sole Proprietor
Partnership
Corporation
LLC
EIN (Tax ID)
Business Website
Contact Information
Contact Name
Phone Number
Email Address
Business Address
City
State
ZIP Code
Coverage Details
Coverage Amount
$500,000
$1,000,000
$2,000,000
Policy Start Date
Do you currently have liability coverage?
Yes
No
Operations & Risk
Number of Employees
Annual Revenue
Describe Business Operations
Describe Claims History
Additional Information
Additional Notes