Commercial General Liability Insurance Quote Request Form – Tim Symes Platinum Insurance Agency

About your business

What does your business do? *

Please select

Will you be the policy holder?

Yes, I am purchasing for my own businessNo, I am acting on behalf of the business ownerThe policy holder is the person or organization who owns the insurance policy.

Please enter your contact details

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Your employees and revenue

How many employees do you have?

What is your estimated revenue over the next 12 months?

USD

This typically may include gross sales, commissions, and fees for your professional services or goods sold.

What is your estimated total payroll over the next 12 months?

USD

Estimate the total amount that you will pay over the next 12 months for: yourself, full-time employees, part-time employees and temporary employees. (Do not include subcontractors 1099). Please note the payroll may be adjusted to meet state requirements.

How much of your total payroll can be considered as owner payroll?

USD

This is the total compensation you estimate owners will receive. If you're a sole owner , enter what your plan to keep for yourself as income in total.

Tailor your policyLet's tailor coverage for you.

Do any of your clients require a waiver or subrogation endorsement?YesNoCustomers typically include this coverage at their client's request. With the waiver, your insurance company agrees to cover all damages in the event of loss and longer has the right to recover costs from your client's insurance.

Do you need to add customers or people you do business with to your policy as 'additional insured(s)?YesNo

If your carrier has not included Terrorism Risk Insurance Act coverage as part of their standard policy, would you like to purchase this coverage as add on?YesNo

When would you like your policy coverage to start?

Please enter the contact details of the business

Business nameThis is the name that will appear on you policy. If you are a sole proprietor and doing business under your own name, please enter your name below.

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Website (Optional)

Additional Notes0 / 140

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