Employment Practices Liability Quote Personal InformationFirst Name *Last Name *Street Address *City *State/Province *ZIP / Postal Code *Phone Number *Alternate Phone NumberEmail Address *Fax#Number of Partners/OwnersLegal EntitySole ProprietorshipSole ProprietorshipC CorporationPartnershipS CorporationLimited Liability corporationOtherNumber of Full Time EmployeesYears In BusinessYears of Owner Experience Within Business?Number of Part Time EmployeesAnnual RevenueUnder $100,000Under $100,000$100,000 - $500,000$500,000 - $1,000,000$1,000,000 - $5,000,000$5,000,000 - $10,000,000Over $10,000,000Annual PayrollLess then $50,000Less then $50,000$50,000 - $100,000$100,001 - $2,000,000$200,001 - $500,000Over $500,000Number of SubcontractorsBrief Description of BusinessSpecific Industry?One Time or Seasonal?YesYesNoDo you have any subsidiary businesses?YesYesNoCompany OwnerOwner First Name *Owner Last Name *Nature of BusinessSquare Footage of LocationAdditional InformationPrior InsuranceLength of Coverage (Month and Years)Have You Had Any Claims Or lapses In Coverage In Past 3 yearsYesYesNoDetails of Claim or LapseHow did you hear about us?Send
