Barbary Insurance Brokerage

General Liability Coverage Quote Request

Please complete the following fields to provide us with enough information to prepare a quote for you. Thank you!

Insured's Name:

Contact Person:

Contact Email:

Mailing Address - Street:

Mailing Address - City:

Mailing Address - State:

Mailing Address - Zip Code:

Phone:

Phone Extension:

Fax:

Location Address - Street:

Location Address - City:

Location Address - State:

Location Address - Zip Code:

Effective Date:

Age of Building or Year Built:

Other Building Occupants:

Square Footage You Occupy:

Describe your business, product or service:

Years in Business:

Projected Gross Annual Receipts:

Projected Annual Payroll:

Previous Insurance Carrier:

Previous Policy Number:

Previous Premium:

Policy Renewal Date:

Do you have any pets?:

If yes, what type?:

Have you had any claims or losses in the past five years?

If yes, please describe:

General Liability Limit:

Non-Owned / Hired Automobile Liability?:

Please list any additional coverages you may need:

Additional Insured - Name:

Address - Street:

Address - City

Address - State:

Address - Zip Code:

Additional Insured Interest:

Please enter the code to the right and click submit: