Liability Quote

About you

Name of Proposer/Company*

Your email*

Your phone number*

Nature of your Business:

Coverage Required

Would you like Employers Liability? If yes, please list number of workers and Annual wage roll:

Would you like Public Liability? If yes, what limit would you like? ($250,000/ $500,000/ 1,000,000/ $2,000,000)*

Insurance History

Any current insurance? If yes, with which carrier

Any losses or claims in the past 5 years?*