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Welcome to Johnson Insurance Management. *** See our privacy statement under get a quote**
General Liability Quote
PLEASE FILL OUT THE FORM BELOW AND SUBMIT FOR A FREE NO-OBLIGATION QUOTE FOR YOUR GENERAL LIABILITY INSURANCE NEEDS:
NORTH CAROLINA RESIDENTS ONLY.
* = Mandatory
Name: *
Leave Blank:
Address 1: *
Address 2:
City: *
State: *
Select State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code: *
Organization:
Home Phone: *
Work Phone:
Fax:
Email: *
Business Application and Detailed Data
General Nature and Type of Business
(Please be detailed)
: *
Business Name: *
Start Date: *
Years In Business: *
Type of Ownership: *
Corporation
Partnership
Individual
What types of Insurance Do You Need
If none of the coverage below is needed, leave blank. These questions are to insure we accurately address your liability needs
General Liability:
Business Personal Property:
Other:
Glass & Signs:
Crime:
Equipment Floater:
Electronic Data:
Builders Risk:
General Liability:
Business Auto:
Vehicle Schedule:
Truckers:
Boiler & Machinery:
Workers Compensation:
Umbrella:
Commercial General Laibility:
Claims Made
Occurrence
Limits
General Aggregate:
Products & Completed Operations Aggregate:
Personal & Advertising Injury:
Each Occurrence:
Fire Damage (Any one fire):
Medical Expense (Any one person):
Employee Benefits:
Other Coverage, Restrictions and/or endorsements::
Schedule of Hazards
Gross Sales On Annual Basis:
Payroll On Annual Basis:
Number Of Locations:
Deductible Per Property Damage:
Questions - Please explain all "yes" responses for past or present operations in the comments section below
Does applicant draw plans, designs, or specifications for others:
Yes
No
Do any operations include blasting or utilize or store explosive material:
Yes
No
Do any operations include excavation, tunneling, underground work or earth moving:
Yes
No
Do your subcontractors carry coverage's or limits less than yours:
Yes
No
Are subcontractors allowed to work without providing you with a certificate of insurance:
Yes
No
Does applicant lease equipment to others with or without operators:
Yes
No
Remarks/Describe the type of work subcontracted:
% of work subcontracted out:
Products /Completed Operations: Please complete if applicable
Products:
Annual Gross Sales:
# of Units:
Time In Market:
Expected Life:
Intended Use:
Principal Components:
Products:
Annual Gross Sales:
# of Units:
Time In Market:
Expected Life:
Intended Use:
Principal Components:
Products:
Annual Gross Sales:
# of Units:
Time In Market:
Expected Life:
Intended Use:
Principal Components:
Any medical facilities provided or medical professionals employed or contracted:
Any exposure to radioactive/nuclear materials:
Do/Have Past, Present, or Discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting of hazardous materials:
Any operations sold, acquired, or discontinued in last 5 years:
Machinery or equipment loaned or rented to others:
Any watercraft, docks, floats, owned, hired or leased:
Any parking facilities owned/rented:
Is a fee charged for parking:
Recreation facilities provided:
Is there a swimming pool on the premises:
Sporting or social events sponsored:
Any structural alterations contemplated:
Any demolition exposure contemplated:
Has applicant been active in or is currently active in joint ventures:
Do you lease employees to or from other employers:
Is there a labor interchange with any other business or subsidiaries:
Are day care facilities operated or controlled:
Have any crimes occurred or been attempted on your premises within the last three years:
Is there formal, written safety and security policy in effect:
Does the business promotional literature make any representations about the safety or security of the premises:
How would you like to receive your quote:
Email
Telephone
Fax
US Mail
