ARG & Associates will provide you with a free, no-obligation General Liability/Business Liability Insurance quote. The information below is kept confidential. Please answer as many questions as possible, so we can provide you with the most accurate quote.


General/Business Liability Insurance

Company Information
 
Company Name:                    Date: 
Contact:             
Address:            
City:                  
State:                
Zip:                   
Phone:                                Best time to call:   am    pm
Fax:                  
E-mail:              


Insurance Information
 
Currently Insured with: 
Policy Number:            Policy Expiration Date:  
Premium Amount: $       Insured Amount: $
Term of Insurance:  6 months    1 year    other: 
What other types of insurance coverage do you have relating to your business? (Please list below):
          Insurance Type                              Premium paid per Year                      Expiration Date
 Business Liability                         $                     
 Business Auto                             $                     
 Business Umbrella                       $                     
 Workers' Compensation                $                     
 Professional Liability                     $                     
 Liability for Corporate Executives   $                     
 Group Health                               $                     
 Group Life                                   $                     
 Group Retirement/401k/etc.          $                     
 Surety Bonds                              $                     
 Other:           $                     


Company Financial Information
 
What was your past years Annual Income: $    Projected Current Year: $ 
Cash: $           Securities: $    Other income: $ 
Amount of inventory:  $ 
Amount of Supplies:  $ 
Amount of Equipment: $ 
Amount of other Assets: $ 
What was your past years Annual Payroll: $   Projected Current Year: $ 
How many years has the company been in business? 
How many Full Time employees do you employ?  
How many Part Time employees do you employ? 
Do you have any contract labor?  Yes    No, if yes, how many contractors do you have? 
Please describe your business below:



Additional Details
Please list below any additional details in the space provided below:


When you click "Submit Quote" button, your application will be emailed to one of our representatives, who will contact you shortly.


      



  This Form: BI2003 is a Copyright © 2003 First e-Commerce Corporation