General Liability Form

General Liability Form
Company Name*
Company Name
Name*

First NameLast Name
# Years Business
# Years Experience
Legal Status:

IncIndividualPartnershipAssocLLC
E-Mail*
Email
Phone Number *
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gross Sales:
FEIN #
# Owners
# Employees: FT
# Employees: PT
Total Payroll: $
Current Insurance:

YesNo
Description of Business in Detail:
Claims/Losses :

YesNoOther
Limits of Liability (required by lease):
Additional Insured/Landlord (Business name, address, fax#)
Please include a copy of your current liability policy, if available (face page)

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NOTES
Who filled this out *

DebbieChrissyFrancinaClient/ Referral
Should be Empty: