General Liability Insurance

The insurance coverage that pertains to claims arising out of the insured's liability for injuries or damage caused by ownership of property, manufacturing operations, contracting operations, sale or distribution of products, and the operation of machinery, as well as professional services.



First & Last Name:

Business License #:

Telephone:

Email Address:

How did you hear about Pike Insurance?

What size T-Shirt do you wear?

What size Hat do you wear?



Company Name:

Years in Business:

Mailing Address:

City:

State:

Zip Code:

Company Telephone:

Company Fax:



Current Carrier:

Current Premiums ($):

Current Expiration Date (mm/dd/yy):

Current Insurance Limits:

Current Excess / Umbrella Liability:

Current Annual Field Payroll ($):

Current Estimated Gross Receipts ($):

Have you ever filed a Claim?	YES (If YES, briefly describe) NO



Percentage of Sub-Contractor(s) usage:



* If applicable, check more than one of the boxes below. PIKE knows that Contractors have many areas of specialization.

Construction Type:	( Combined, the fields MUST TOTAL 100% )

	Non-Structural Remodel New Construction Structural Remodel Service / Repair

Structural Type:	( Combined, the fields MUST TOTAL 100% )

	Residential Industrial Commercial

Description of Operations:

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