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General Liability Insurance

General Liability Form

First Name:

Last Name:

Phone:

Email:

Business Name:

Legal Entity Type:

Brief Description of Business:

Business Address:

Do You Lease or Own The Space

Square Footage Of Entire Building

Square Footage You Occupy

Date business was established:

Federal EIN:

Years in Business:

Years of Experience:

# Full Time Employees:

# Part-Time Employees:

Estimated Gross Revenue:

Estimated Payroll for Next 12 Months:

Total Value Of Your Business Personal Property(BPP) At This Location?

Do you have insurance right now?

Yes

If Yes, how long have you had it?

Preferred method of contact

Additional Info

What type of coverages are you looking for (select all that apply):

General Liability

Professional Liability

Workers Comp

Cyber

Inland Marine

Umbrella

Life

Business Auto Policy

Commercial Auto

Event Liability

Surety Bond

Home

Rent

LegalShield

IDShield

Notary

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3329 W Sunset Ave. STE B,

Springdale AR 72762

479-318-2775

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