Insurance Applications / Commercial General Liability Application

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Total value of all machinery and equipment (owned and leased) *

Personal information about you, including information from a credit or other investigative report, may be collected from persons other than you in connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to help determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection with the development of your score. You may have the right to review your personal information in our files and request correction of any inaccuracies. You may also have the right to request in writing that we consider extraordinary life circumstances in connection with the development of your credit score. These rights may be limited in some states. please contact your agent or broker to learn how these rights may apply in your state or for instructions on how to submit a request to us for a more detailed description of your rights and our practices regarding personal information. Finally, we'll ask you to sign the form, certifying that the information you just provided to questions on this application are orrect and complete to the best of his/her knowledge.

We are independent insurance brokers and risk managers participating in the insurance transaction as trusted advisors. We represent you, the insured, in the insurance marketplace, assembling and understanding the information and specifications used to market and ultimately place insurance programs.. read more

We have exciting career opportunities for licensed insurance professionals. We are seeking agents/brokers with or without existing book of business, who can prospect and sell Commercial Lines and/or Personal Lines Insurance.. let's start the conversation!

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16461 Sherman Way
Suite 350
Lake Balboa, CA 91406

Washington Office
12819 SE 38th St.
Suite 430
Bellevue, WA 98006

Telephone
(818) 464-4444

Fax
(888) 543-1210

Commercial General Liability Application

Applicant Information

Business Contact(s) Information

Current/Prior Insurance Information

Owners/Officers Information

Business Information

Business Personal Property and Business Income

Building Information

Rating/Underwriting Information

Signature and Certification