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Phone: (800) 750-8888
Fax: (866) 353-3083
Commercial General Liability Insurance
One Simple Form - takes only 2-3 Minutes!
YOUR PERSONAL DATA
Your Name:
Business Name:
Property Address:
City:
State: (Must be California)
Zip/Postal:
E-Mail: (Required)
Phone:
Fax (Optional):
Your Company Website:
UNDERWRITING INFORMATION
Date Coverage Needed:
Prior Carrier:
Describe Business:
Gross Annual Receipts:
$
Gross Annual Payroll:
$
Square Footage of Your Business Location:
$
Number of Employees:
What kind of commercial coverage you are looking for, and why:
Prior Claims?
Yes
No
Describe claims in detail:
LIMITS & COVERAGES:
Liability Limits:
$100,000
$300,000
$500,000
$1 Million
Business Contents Needed?
If so, list type and amount:
Comments/Remarks:
Send my quotation via:
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to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency release this information via the method you have chosen, and to
release us any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
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HAD / Professional Insurance Associates, Inc | Mailing Address: P.O. Box 8480, Porter Ranch, CA 91327
1100 Industrial Road, Suite 3, San Carlos, CA 94070 | 6320 Canoga Avenue, Suite 1500, Woodland Hills, CA 91367
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