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General Liability Quote Form
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Fax (optional):
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Limit of Liability
Coverage Requested?
$1 Million
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
Number of Active Owners:
Number of Employees (full & part time):
Annual Employee Payroll: $
Annual Gross Sales: $
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

Other Coverages You Would Like Information On: Tool & Equipment Floater Commercial Vehicle
Bonds, License/Performance
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Jay P. Stoetzer Insurance
5750 W. 95th Street, Suite 105 | Overland Park, KS 66207
Toll-Free: 855-EZQUOTE
Local Phone: 913-221-7764 | Fax: 913-385-3500
About Our Agency | Privacy Notice | Office Map/Directions

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