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Asia Insurance Business General Liability Quote

Customer Information
Business Name
First Name	Middle Initial	Last Name
Street #	Street Name	Apt or Unit
City	State	Zip	-
Home Phone	Work Phone	Email

Desired Limits: (Each Occurrence / General Aggregate) (other limits may be available upon request)	$300,000/$600,000	$500,000/$1,000,000	$1,000,000/$2,000,000
What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?
Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above).
Liquor Liability	Yes No	If yes, please provide annual Liquor Receipts
Hired and Non-owned Auto Liability	Yes No	Stop Gap Liability (ND,OH, WA, WV and WY only)	Yes No
Employee Benefits Liability	Yes No	Limited International General Liability Extension Endorsement	Yes No
Please indicate whether any of the following exclusions are desired.
a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages)			Yes No
b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages)			Yes No

Wholesale Applicants ONLY
Are all goods manufactured domestically or by a company with a location in the US?	Yes No
AIf no, is Imported Products Liability Coverage desired?	Yes No
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products?
Do you do any repackaging, re-labeling, repair or re-manufacturing of products?	Yes No

Please use the space below to add comments regarding any special circumstances or coverage needs

Disclosure

Where permitted by law, the insurance companies we quote will individually confirm your information through consumer reports, which may include credit reports. Each company will provide the source of the report if you are interested. Your information may be shared with the quoting company's affiliated underwriting companies, independent representatives or other insurance partners.

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