Please complete the following general questionnaire. Our professional, courteous staff will contact you regarding your quote. Or call us at 1 (800) 779-PARS

General Information

Insured's Name

Phone Number

Fax Number

Email Address

Insured is

Please Choose Individual Partnership Corporation Joint Venture

Business Name

Street Address

City

Zip Code

CA

Number of Owners

Number of Partners

Number of Full-Time Employees
Number of Part-Time Employees

Employees Payroll

What Percentage of work is subcontracted %

Estimated Receipts Current Year
Estimated Receipts Next Year

Loss History

Prior carrier and loss history for the past three years

From Mo. Yr. To Mo. Yr.

Company Name

Policy number

Cancelled or Non-renewed

No Yes

Reason

Nature of Business/Description of Operation:

Desired Coverages
Comprehensive General Liability
Coverage Per Occurrence	00,000
Coverage Aggregate	00,000
Property Coverage
Cargo Coverage (if required)
Hired (if required)
Non-owned (if required)

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