Welcome to The Accord Insurance Network!

Commercial General Liability

We would like to provide you with a free, no-obligation quote for your business. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Company or Name
Contact
Address
City
State
Zip
Phone		Ext
Alternate Phone		Ext
Fax
Email
Respond back by
Effective Date Requested	Month Day
Fein or S.S.#
Business Experience	Years Experience
	Year Started Business
Entity Type
Nature of Business

General Liability
Please provide us the desired limits you are looking for. If you do not know we will call you:
Liability
Professional Liability
Products/Completed opps Liability
Property rented
Medical Expenses
Deductible
Payroll	(minimum 15,000)
Sales

Property Coverage
This will give us a basic idea of what you are looking for. We will call or email you for more information if we need it. We will rate all on a replacement cost assuming a 90% coinsurance value.
Deductible
Property
Betterments
Business income
Other Coverage
Amount

Premise Information
Location 1
Street
City
County
Zip code
City Limits	Inside Outside
Ownership Interest	Own Rent
Year Built
Square Footage
Part Occupied
Construction Type
Roof Type
Monitored Alarm	Y N
Location 2
Street
City
County
Zip code
City Limits	Inside Outside
Ownership Interest	Own Rent
Year Built
Square Footage
Part Occupied
Construction Type
Roof Type
Monitored Alarm	Y N
Additional Locations	Enter the information requested above for any additional locations below:

Rating Information (Explain all yes answers in remarks below)
Are you a subsidiary of another entity	Y N
Do you have a formal safety program	Y N
Any Exposures to Flammables, Explosives, Chemicals?	Y N
Any Catastrophic Exposures?	Y N
Any policy or coverage declined, cancelled or non-renewed in past 3 years?	Y N
Any past losses due to sexual abuse or molestation allegations, discrimination, negligent hiring?	Y N
During the past 10 years, has any applicant been convicted of any degree of the crime of arson?	Y N
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?	Y N
Remarks for all yes answers:
Additional Comments or requests:




	Copyright � 2007, Accord Insurance Network. All rights reserved. No portion of this site may be reproduced in any manner without the prior written consent of Accord.