Get a General Liability Quote | J & A Insurance Agency

General Liability Quote Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Owner

First Name *

Last Name*

Nature of Business

Number of Owners

Gross Annual Sales

Number of Employees

Annual Employee Payroll

Subcontractors Used

Annual Cost of Subcontractors

Square Footage of Location

Additional Information

Prior Insurance

Length of Coverage (Months and Years)

How many additional insureds are required?

Approximately how many insurance certificates (ie. COI’s) do you require annually?

Do you have any special insurance requirements (ie. Additional Insured designations, Waiver of Subrogation etc.)?

If so please upload copies of any sample insurance certificates that you were given and/or a copy of the insurance requirements

Are you currently operating without insurance?

If so please explain why

Any prior claims? If so please explain.

Has any current/previous policy been cancelled or non-renewed within the last 5 years? If so please explain

How many physical locations does the business have?

Please list the city/state for each location.

How much coverage is needed to cover office contents?

**Please note that coverage for tools/equipment travelling offsite must be requested separately and is NOT automatically included**

How did you hear about us?

Submission Validation*

Important Notice

Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

General Liability Quote Form

General Liability Quote Form

Company Information

Company Owner

Additional Information

Important Notice

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