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On-Line Commercial General
Liability Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name:
Business Name:
Property Address:
City:
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Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Underwriting Information
 
Primary Policy Holder's Social Security Number or Corporation Federal Tax ID#:
(Some carriers use credit history to qualify, this information is REQUIRED)
 
Date Coverage Needed:
 
Prior Carrier:
 
Describe Business:
 
Gross Annual Receipts: $
 
Gross Annual Payroll: $
 
Square Footage of
Your Business Location: 		$
 
Number of Employees:
 
Tell us what kind of
commercial coverage you
are looking for, and why:
 
Prior Claims? Yes No
Describe claims in detail:
 

Limits & Coverages:
Liability Limits: $100,000    $300,000
$500,000    $1 Million
 
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Griffin Insurance Group Inc. . 209 S. Main Street . Zelienople, PA 16063
Toll Free Phone: 1-888-500-3743 . Phone: 1-724-453-1122 . Fax: 1-724-453-1123
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