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ASENA CAPITAL

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General Liability Quote Form

Legal Business Name:*

Full Name*

First Name and Last Name

Doing Business As (DBA):

Business Address: *

Business Phone:*

Email: *

Website:

Business Entity Type: *

Sole Proprietorship

LLC

S Corp

C Corp

Partnership

Other

Federal Tax ID (EIN):*

Years in Business:*

Date Business Started:*

Detailed Description of Business Operations: *

NAICS or SIC Code:

Primary Business Activity:

Percentage Breakdown of Activities:

Annual Gross Sales/Revenue: *

Number of Employees:*

Does the Applicant Hire Subcontractors? *

No

Yes

If yes, do you require Certificates of Insurance.

Does the Applicant Perform New Residential Work Prior to Certificate of Occupancy?*

No

Yes

Percentage of Work Performed On-Site vs. Off-Site:*

Do you work at customer locations? :

No

Yes

Do you work on government contracts? :

Yes

No

Do you provide professional services? :

No

Yes

If yes, describe

Do you manufacture, distribute, or sell products? :

No

Yes

If yes, describe.

Do you import or export products? :

No

Yes

If yes, describe.

Do you handle or store customer property? :

No

Yes

If yes, describe.

Desired Coverage Limits: *

Per Occurrence Limit

General Aggregate Limit

Products/Completed

Operations Aggregate Limit

Personal and Advertising Injury Limit

Damage to Premises Rented to You Limit

Desired Policy Effective Date:*

Specific Coverage Needs:

Do you rent commercial space? :

Yes

No

Prior Insurance Claims History:

Any Pending Lawsuits or Claims?

Sub-Contracting Costs*

Cost of single or specific subcontract engagement

Total Annual Sub-Contracting Cost*

Gross Receipts *

Total Annual Active Employee Payrol*

Do you have contracts requiring specific insurance? :

Yes/No. If yes, describe.

Do you work outside of your state? :

Yes

No

Share any other details about your business that you think we should know to provide the most accurate quote.

any additional information about your business

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