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FAX Check Form
 
GENERAL LIABILITY
This is not an application, Underwriter may ask for completed application before quoting.
GENERAL INFORMATION
Agent:  Date: 
Agent's Phone # Agent's Fax #
Agency's Email: 
Insured: 
Insureds Telephone: 
SS# or Tax ID:  (required for Artisan quotes)
Location Address : 
City :   County :     
State :  Zip :     
   
BUSINESS INFORMATION
Type of Business (Give Complete Description) : 
If construction related, must have Tax ID or SS#:
Years in Business : 
Is any of their work involved with NEW construction?   Yes No
Business Size : Sq Feet      
Payroll  :  (excluding owner).      
Annual Gross sales  :                                Restaurants :  % of Alcohol Sales  
# of Owners & Partners Annual Payroll $ 
# of All Other Employees Annual Payroll $ 
# of Units :    # of Pools  :    
SUBCONTRACTORS
Please also complete a Contractor's Supplement and include with this application
Amount of subcontracted work: %      
Amount spent on subs: $      
Currently insured? Yes No
Do Subcontractors carry insurance No  :  Yes No
Certificates Obtained  :   Yes No
           
LIMITS
Gen.Agg.$ Occurance $
Products/Comp OPS $ Excl.          Fire Damage$ Excl.
Personal/Adv Inj. $ Excl.                 Med. Pay$ Excl.
         
Loss Information (Past 3 Years, if None, state None)

Prior Carries (Past 3 Years):
Comments
   
    
 
  Turner General Agency, Inc.
Phone: (888) 443.7932 ~ (972) 290.7200		 Fax: (972) 203.8206 Email: Brett Turner at 
brett@turnercompanies.com  		 

 


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