Home Page Facebook Twitter LinkedIn

General Liability & Property Information


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.

Contact Information
First Name
Required
Last Name
Required
Business Name
Required
Website
Optional
E-Mail Address
Required
Primary Phone Number
Required
Business Entity Type
Required



Year Business Established
Required
F.E.I.N.
Required
In the past 3 years, have there been any losses/claims, cancellation or non-renewals with existing insurance carrier?
Required

Annual Gross Sales
Required
Current Carrier
Optional
Premium
Optional
Expiration Date
Optional
/ /
Property Information
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Building Limit
Required
Business Personal Property Limit (Replacement Cost)
Required
Deductible
Required




Location Details
Year of Construction
Required
**If > 30 years old, complete updates below.
Date of updates
Wiring
Optional
Roof
Optional
Plumbing
Optional
Heat
Optional
Are there circuit breakers?
Optional

Aluminium wiring
Optional

Sprinklered
Optional

Number of Stories
Optional
Square Footage
Required
**If > 10,000 sq feet & fire walls present, what is the area between?
Required
Square footage you occupy
Required
Construction Type (Select One)
FRAME: Exterior walls of wood or other combustible materials, including construction where combustible materials are combined with other materials, such as brick veneer, stone veneer, wood iron clad, or stucco on wood
Optional
JOISTED MASONRY : Exterior walls are constructed of masonry materials such as adobe, brick, concrete,gypsum block, hollow concrete block, stone,tile or similar material and where floors and roof are combustible
Optional
LIGHT NON-COMB : Exterior walls, floors, and roof are constructed of and supported by metal, gypsum or non combustible material
Optional
HEAVY NON-COMB/ FIRE RESIST : Exterior walls are constructed of masonry materials {adobe, brick, concrete, gypsum block, hollow concrete block, stone or tile} or other fire resistive materials
Optional
Is there a Loss Payee/Mortgagee (lienholder) for any of this property?
Required

If so, do they need to be listed on the policy as a Loss Payee or Additional Insured?
Optional

General Liability
Typically we offer limits at $1,000,000 per occurrence with a $2,000,000 aggregate. Please advise if different limits are required.
Is there a landlord/property owner that needs to see the general liability coverages?
Required

If so, do they need to be listed as "Additional Insured" on the policy (for the office space).
Optional

Please provide the name of Landlord
Optional
Please provide the address of Landlord
Optional
Please list # of 1099 subcontractors
Required
Annual revenue
Required
# of Employees (if more than zero, then annual payroll)
Required
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
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.

© Aegis Alliance Insurance Agency, All Rights Reserved | 844-692-3447 | Home Office: 13804 Hull Street Road, Midlothian, Virginia 23112