Arkansas HVACR NewsMagazine November 2021

L IABILITY I NSURANCE Q UOTE F ORM

General Information

Company Name (& DBA):

Address:

FEIN:

Contact Name:

Years in Business:

Contact Number:

Website Address:

Contact E-Mail:

General Liability

Total Annual Revenue:

New Installation

vs

Servicing

Revenue %:

Residential

vs

Commercial

Workers Compensation

Estimated Annual Payroll:

Employee Count:

Clerical:

Technician :

Auto

Vehicles (# of Each):

Sedan:

Box Trucks:

SUV/Pickup Trucks:

Trailers:

Tractors:

Will Need VINs and Driver Information (Name, DOB, DL #) For Most Accurate Pricing

Current/Prior Coverage

Do You Currently Have Insurance Coverage? Y / N

Have You Had Any Prior Insurance Claims? Y / N