Home > Employees > Liam Jones

Liam Jones

Quote Manager

Phone: (800) 996-9515 ext. 303

Get A Quote

Full Name*

Email Address*

Phone*

Address*

Type of Insurance*

Auto Insurance Quote

Current Insurance Information

Insurance Company Name:

(NOT Insurance Agency/Broker)

Premium Amount:

How long have you been with them?

Policy Exp. Date:

Vehicle Information

How many vehicles do you want to insure?

Vehicle #1:

Year

Model

Make

Vin #

Yearly Mileage

Alarm

Usage

Any Custom equipment on vehicle? (if YES, indicate their value).

Debris hauled for others?:

Trailer Hitch?:

Class of Business:

Vehicle #2:

Year

Model

Make

Vin #

Yearly Mileage

Alarm

Usage

Any Custom equipment on vehicle? (if YES, indicate their value).

Debris hauled for others?:

Trailer Hitch?:

Class of Business:

Vehicle #3:

Year

Model

Make

Vin #

Yearly Mileage

Alarm

Usage

Any Custom equipment on vehicle? (if YES, indicate their value).

Debris hauled for others?:

Trailer Hitch?:

Class of Business:

Vehicle #4:

Year

Model

Make

Vin #

Yearly Mileage

Alarm

Usage

Any Custom equipment on vehicle? (if YES, indicate their value).

Debris hauled for others?:

Trailer Hitch?:

Class of Business:

Coverage Information

Liability limits for bodily injury & property damage:

Uninsured Motorist Bodily Injury:

Deductibles

Vehicle #1:

Comp. & Collision

Towing coverage

Rental Reimbursement

Vehicle #2:

Comp. & Collision

Towing coverage

Rental Reimbursement

Vehicle #3:

Comp. & Collision

Towing coverage

Rental Reimbursement

Vehicle #4:

Comp. & Collision

Towing coverage

Rental Reimbursement

Driver Information

How many drivers do you want to add to your policy?

Driver #1:

Name

Date of birth

Driver's License #:

Years Licensed:

Occupation:

Sex

Marital Status:

Driver's Education or Defensive Driving Courses?

SR 22 filing?

Driver #2:

Name

Date of birth

Driver's License #:

Years Licensed:

Occupation:

Sex

Marital Status:

Driver's Education or Defensive Driving Courses?

SR 22 filing?

Driver #3:

Name

Date of birth

Driver's License #:

Years Licensed:

Occupation:

Sex

Marital Status:

Driver's Education or Defensive Driving Courses?

SR 22 filing?

Driver #4:

Name

Date of birth

Driver's License #:

Years Licensed:

Occupation:

Sex

Marital Status:

Driver's Education or Defensive Driving Courses?

SR 22 filing?

Accidents / Violations in the last 5 years?

Driver #1:

Minor violations (speeding, turn, stop sign, red light):

Accidents - non chargeable

Accidents - chargeable:

Chargeable Accident Cost($):

Major violations (drunk driving, reckless, hit and run)

Driver #2:

Minor violations (speeding, turn, stop sign, red light):

Accidents - non chargeable

Accidents - chargeable:

Chargeable Accident Cost($):

Major violations (drunk driving, reckless, hit and run)

Driver #3:

Minor violations (speeding, turn, stop sign, red light):

Accidents - non chargeable

Accidents - chargeable:

Chargeable Accident Cost($):

Major violations (drunk driving, reckless, hit and run)

Driver #4:

Minor violations (speeding, turn, stop sign, red light):

Accidents - non chargeable

Accidents - chargeable:

Chargeable Accident Cost($):

Major violations (drunk driving, reckless, hit and run)

Homeowners Insurance Quote

Current Insurance Information

Insurance Company Name:

(NOT Insurance Agency/Broker)

Policy Exp. Date:

Mortgage Amount:

Term:

Amount Insured for:

Premium Amount:

Any Claims in Last 3 years?

General Information About Your Home

Year Built:

Years at present address:

Liability coverage:

Distance to nearest fire hydrant:

Distance to nearest fire department:

Home Type:

Roof Type:

Roof's Age:

Number of Bedrooms:

Number of Bathrooms:

Foundation:

Total Square Footage:

Market Value:

Home Construction:

Garage Size:

Garage Type:

Number of Fireplaces:

Exterior:

Basement Finished?

If finished, what percentage? (%)

Additional Information

Swimming Pool?:

Diving Board:

Smoke Detector:

Heating System:

Pool Fenced:

Trampoline:

Security System:

Fire Alarm:

Replacement cost of personal items:

Any business conducted in home:

List values of any jewelry, furs, or specialty items:

List pets and breeds:

Do you want to include Flood Insurance?

Condominium Insurance Quote

Current Insurance Information

Insurance Company Name:

(NOT Insurance Agency/Broker)

Policy Exp. Date:

Contents Insured for:

Premium Amount:

Current Deductible:

Policy Term:

General Information

Will you or do you live on this property:

How much coverage do you want on your personal property:

How much personal liability:

How much Deductible:

Number of Units:

Number of Stories:

Is there a 24-hour door man:

Are there elevators:

Year Built:

Approximate Square Footage:

Have you reported any claims or losses to your insurance company within the last 5 years?

Type of Construction:

Roof Type:

Roof Age:

Burglar Alarm:

Heating System:

Number of gas or wood fireplaces or stoves:

What floor do you live on:

Number of bathrooms:

Additional Information

Any business conducted in home:

If yes, please describe

List values of any jewelry, furs, or specialty items:

List pets and breeds:

Flood Insurance Quote

Flood Zone:

County:

Building Occupancy:

Condo Association and Residential Building?

Has property incurred 2 or more losses?

Replacement Cost:

Total Building Coverage:

Total Contents Coverage:

Building Type:

Construction Date:

Number of units in building:

Condominium Association:

Basement / Enclosure of Crawl Space:

Does enclosure or crawl space area have compliant venting:

Finished Area:

Machinery / Equipment:

Building Elevated:

Lowest floor which includes living area, is off the ground by means of:

Area used for:

Square foot area:

Enclosure Walls:

Contents Location:

Is building flood proofed:

Business General Liability Insurance Quote

Name of Business:

Business Phone:

Fax Number:

Limits & Coverage

Desired Limits: (Each Occurrence / General Aggregate) (other limits may be available upon request)

What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?

What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?

Optional Coverages:

(The limits provided will be the same as the limits chosen above)

Employee Benefits Liability

Liquor Liability

If yes, please provide annual Liquor Receipts ($)

Hired and Non-owned Auto Liability

Stop Gap Liability (if applicable)

Limited International General Liability Extension Endorsement

Exclusions:

Indicate whether any of the following exclusions are desired

General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).

General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).

Wholesale Applicants ONLY

Are all goods manufactured domestically or by a company with a location in the US?

If no, is Imported Products Liability Coverage desired?

If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products?

Do you do any repackaging, re-labeling, repair or re-manufacturing of products?

Builder/Contractor General Liability Insurance Quote

Contact Information

Business Name:

Inspection Contact Name:

Business Address:

Business Phone:

Business Status:

Years in Business:

Current Insurance Information

Current Insurance Carrier:

Effective Date:

Expiration Date:

Premium ($):

Please List Any Other Previous Carriers Over the Past 3 Years Below:

Carrier Name:

Premium ($):

Use the "+" icon to the right to list additional carriers.

Project/Work Information

Please write a Description of Operations below:

What percentage of your work is: (each line must total 100%)

Commercial (%)

Industrial (%)

Residential (%)

What percentage of your work is as a: (each line must total 100%)

New Construction (%)

Remodel/Additions (%)

What percentage of your work is as a: (each line must total 100%)

Subcontracted Out (%)

Sub Costs (%)

Do you collect certificates of insurance at a $1,000,000 limit?

Receipts / Payroll / Dollar Value Info

Gross receipts for third year prior:

Gross receipts for second year prior:

Gross receipts for last twelve months:

Gross receipts for next twelve months:

Number of owners/officers/partners active at the job site or supervising:

Payroll of employees excluding owners, officers, partners & clerical: ($)

Dollar value of average job completed including all materials, labor & equipment: ($)

Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info

Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:

Have you ever been named in litigation regarding faulty construction?:

Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:

Claims History

Have you ever filed a claim?

How many?

Claim #1

Date of occurrence:

Date of claim:

Type description of occurrence or claim:

Amount paid on your behalf: ($)

Amount reserved: ($)

Claim Status:

Claim #2

Date of occurrence:

Date of claim:

Type description of occurrence or claim:

Amount paid on your behalf: ($)

Amount reserved: ($)

Claim Status:

Business Owners Quote

Contact Information

Name of Business:

Business Address:

Business Phone:

Business Fax:

Current Insurance Information

Current Insurance Carrier:

Expiration Date:

Premium Amount ($):

What type of coverages do you currently have?

Your Business Information

Number of full-time employees

Number of part-time employees

How long have you been in business?

How many locations?

Estimated Annual Payroll ($)

Please give a brief description of your business:

Please select the type of coverages you are interested in:

Apartment Building Insurance Quote

Contact Information

Name of Business:

Business Phone:

Business Fax:

Property Information

Premises Address:

Property Type:

Number of units:

Building Square footage:

Year Built:

Occupancy Type:

Plumbing type:

Foundation Type:

Type finished basement, if any:

Type of Roof:

Type of Siding:

Number of stories:

Number of feet to nearest fire hydrant:

Number of miles to nearest fire station:

Currently Insured?

Name of Carrier & how long insured?

Coverages

Building Coverage ($):

Liability Coverage ($):

Contents ($):

Deductible ($250, $500, $1,000, etc.)

Other Coverage/Remarks:

Describe any extra coverage's needed such as business interruption, robbery, computers, etc.

Any claims reported on this property or previously owned properties in the last 3 years?

Please describe (Include date(s) and details of claim):

Date

Description

Amount Paid

Amount Reserved

Open/Closed

Add more claims by clicking the "+" icon to your right.

Property Liability Quote

Contact Information

Name of Business:

Business Phone:

Business Fax:

Property Address:

Years in Business:

Description of Operations or SIC code(s):

Current Insurance Information

Current Insurance Carrier:

Expiration Date:

Premium Amount: ($)

Annual Sales: ($)

Payroll: ($)

Business Income: ($)

Other Insurance Company Used Within Past 3 Years:

Policy Number:

Any losses past 3 years:

List losses' details:

Amount paid ($)

Description of losses

Coverage's Desired

Liability Limit Desired:

Choose other liability limit amount:

Deductible Desired:

Umbrella Amount Desired:

Building Information

Building Value: ($)

Contents Value: ($)

Total Building Area:

Year Built:

Construction Type:

Sprinklers:

Electrical Type:

Amps

Electrical Renovation Year:

Plumbing Renovation:

Plumbing Renovation Year:

Heating Type:

Heating Renovation Year:

Roofing Renovation:

Roof Age (years):

Central Alarm:

List Neighboring Businesses' Distance:

To the right:

To the left:

To the rear:

Restaurant Insurance Quote

Contact Information

Name of Business:

Business Phone:

Business Fax:

Property Address:

Current Insurance Information

Current Insurance Carrier:

Expiration Date:

Premium Amount: ($)

Your Business Information

Number of years In business under current ownership?

Number of years at this location?

Has the owner ever been involved in a bankruptcy or business failure?

lf needed, will financial statements be provided prior to binding?

What are the gross sales for past 3 years:

Year

Food

Liquor

Add each additional year by clicking the "+" icon to your right.

What are the hours of operation?

Is the business seasonal?

Months of operation:

Is there a bar or lounge?

If yes, describe

Is there a Happy Hour?

If liquor is served, describe the training protocol for liquor servers

Is there live entertainment?

If yes, describe type, nights per week, hours, etc.).

Is there a dance floor(s)?

If yes, what is its size?

Are there any operations away from the premises, such as catering?

If yes, explain

Any tableside cooking or food preparation?

Was the building originally built as a restaurant?

If no, has wiring, etc., been updated for restaurant occupancy?

If Yes, When?

Which floor is the restaurant located on?

Maximum seating capacity of restaurant:

Maximum seating capacity of lounge:

Number of exits:

Are all exits free of obstruction, lighted and marked with exit signs?

Is there emergency lighting?

Has insured ever been cited by Board of Health?

If yes, explain

Housekeeping:

Valet Parking?

Is there a coat check room?

Are all areas over ranges grills, fryers, and all other cooking surfaces, and hoods and ducts protected by a ULB00-compliant automatic fire extinguishing system?

Is there a maintenance agreement to regularly inspect and service the system?

Number of Times per year

Are the employees trained in the use of the automatic extinguishing system and portable fire extinguishers?

Is there a maintenance agreement with an outside firm to clean the hood and duct system?

Times per year

If no, explain

How often are the grease filters cleaned by the employees?

Liquor Liability Insurance Quote

Contact Information

Name of Business:

Business Phone:

Business Fax:

Location Address:

Current Insurance Information

Current Insurance Carrier:

Expiration Date:

Premium Amount: ($)

Your Business Information

How long have you been at this location:

How long have you been in business?

Name on license:

Expiration date of license:

Describe your operation:

(i.e... private club, gas station, tavern or bar with nightclub entertainment, etc)

Commercial Umbrella Insurance Quote

Contact Information

Name of Business:

Business Phone:

Business Fax:

Location Address:

Current Liability Coverage

Current Insurance Carrier:

Effective Date:

Expiration Date:

Premium Amount: ($)

Policy Information:

Per Claim Aggregate ($):

Limits of liability ($):

Current Retroactive Date:

Primary Location Information

Annual Payroll ($):

Annual Gross Sales ($):

Foreign Gross Sales ($):

Underlying Insurance Information

Auto Liability:

Carrier:

Policy Number

Limits ($):

Effective Date:

Expiration Date

Annual Premium ($):

General Liability:

Carrier:

Policy Number

Limits ($):

Effective Date:

Expiration Date

Annual Premium ($):

Employer's Liability:

Carrier:

Policy Number

Limits ($):

Effective Date:

Expiration Date

Annual Premium ($):

Garage Owners Quote Request

Business Information

Business Entity:

Years In Business:

Years Sales/Repair Experience:

Describe your Operations:

Locations Information

In how many locations do you conduct business operations?

Business Address #1:

Business Address #2:

Underwritting Information List of Drivers (Owners, Employees, Family)

How many drivers do you want to add to your policy?

Driver #1

Full Name

Drivers License #:

State of License:

Date of Birth

Furnished Auto:

Job Description and / or Relation:

Number of Citations in the Past 3 Years:

Number of Accidents in the Past 3 Years:

Driver #2

Full Name

Drivers License #:

State of License:

Date of Birth

Furnished Auto:

Job Description and / or Relation:

Number of Accidents in the Past 3 Years:

Number of Citations in the Past 3 Years:

Driver #3

Full Name

Drivers License #:

State of License:

Date of Birth

Furnished Auto:

Job Description and / or Relation:

Number of Accidents in the Past 3 Years:

Number of Citations in the Past 3 Years:

Driver #4

Full Name

Drivers License #:

State of License:

Date of Birth

Furnished Auto:

Job Description and / or Relation:

Number of Accidents in the Past 3 Years:

Number of Citations in the Past 3 Years:

Sales

Where do you purchase vehicles?

Who drives or tows vehicles to your lot?

How many times per year do you drive-away more than 300 miles from point of purchase?

How many vehicles do you sell per year?

How many of those are on consignment?

What is your normal radius of operation?

What is your sales mix percentage (%)?

cars, sport utility, pickups, vans

motor homes

travel trailers, camp trailers

trucks, tractors, semi-trailers

salvage parts

Describe your theft barriers

Describe your key controls

How many dealer plates do you have?

Do you repossess vehicles?

If yes, explain

Do you sell "salvage titled" vehicles?

If yes, what percentage (%) of vehicles require:

Cosmetic Repair

Mechanical Repair

Structural Repair

Do you always ride along on test drives?

Services

What percentage (%) of your work is:

Body/Paint (%):

Tune Up (%):

Transmission (%):

Brakes (%):

Sound System (%):

Tires (%):

Wash/Detail (%):

Muffler (%):

Radiator (%):

Wheel Alignment (%):

Oil & Lube (%):

Window Tint (%):

Upholstery (%):

Do you sell gasoline or LPG?

If yes, how many gallons:

Do you install trailer hitches?

Do you have a spray paint booth?

If yes, is it U/L approved?

If yes, is it ventilated?

Do you recap tires or sell recapped tires?

Do you tow for hire?

If yes, explain

Prior Carrier and Loss History for 3 Years

List carrier details:

Carrier Name

Policy Period

Policy Premium ($)

Add any extra carriers by clicking the "+" icon to your right

Any losses in the past 3 years:

List losses' details:

Date

Amount paid ($)

Description of losses

Coverage Requested

Select all that apply to your needs from these boxes:

Garage Liability

Legal Liability for Garage-keepers

Dealers Physical Damage

Garage Liability Amount ($)

Each Accident Amount ($)

Aggregate, Deductible ($)

Legal Liability Amount per location ($/location)

SCL deductible ($)

Collision deductible ($)

Dealers Physical Damage per location ($/location)

SCL deductible ($)

Collision deductible ($)

Type of Cars:

Vehicle Information

How many vehicles do you want to insure?

Vehicle #1:

Year:

Make:

Body Type:

V.I.N:

GVW:

Radius:

Use:

Loss Payee:

Vehicle #2:

Year:

Make:

Body Type:

V.I.N:

GVW:

Radius:

Use:

Loss Payee:

Vehicle #3:

Year:

Make:

Body Type:

V.I.N:

GVW:

Radius:

Use:

Loss Payee:

Vehicle #4:

Year:

Make:

Body Type:

V.I.N:

GVW:

Radius:

Use:

Loss Payee:

Other Requests:

Interests Covered:

Owner

Owner and Creditor

Consignment Owner

Uninsured Motorist Amount ($):

Personal Injury Protection Amount ($):

Fire Legal Liability Amount ($):

Buy-backs:

GK Transit Limit ($):

Drive-Away Miles ($):

Value per Auto ($):

Professional Liability Insurance Quote

Contact Information

Business Phone:

Business Fax:

License Number:

Primary Practice Address:

Practice Information

Check each that applies to your practice:

Individual

Partnership

Association

Group

Practice

Professional

Affiliation

Current Professional Liability Coverage

Current Insurance Carrier:

Limits of liability ($):

Per Claim Aggregate ($):

Effective Date:

Retroactive Date:

Premium Amount ($):

Professional Information

Occupation:

Specialty:

Practice Operates:

Board Certified:

Claims History

Do you have a claims history?

If so, how many?

Claim #1

Claimant Name:

Date of occurrence:

Insurance Carrier:

Location of occurrence:

Allegations:

Amount paid on your behalf ($):

Amount reserved ($):

Claim Status:

Claim #2

Claimant Name:

Date of occurrence:

Insurance Carrier:

Location of occurrence:

Allegations:

Amount paid on your behalf ($):

Amount reserved ($):

Claim Status:

Claim #3

Claimant Name:

Date of occurrence:

Insurance Carrier:

Location of occurrence:

Allegations:

Amount paid on your behalf ($):

Amount reserved ($):

Claim Status:

Workers Compensation Quote

Current Insurance Information

Insurance Company Name:

Any losses in last 3 years?

Number of claims:

Claim amount paid ($):

Premium Amount ($):

Policy Expiry Date:

MOD Factor:

Policy Number:

Describe the type of Coverage you currently have:

Prior Carrier Info

Insurance Company Name:

Number of claims:

Claim amount paid ($):

Premium Amount ($):

How long were you with them?

MOD Factor:

Policy Number:

About Your Business

Number of Full-time Employees:

Number of Part-time Employees:

Owner's Name:

Fed Tax ID:

License Type:

Years in Business:

License Number:

Number of locations:

Annual Gross Sales:

Square Footage:

Estimated payroll / month:

Type of Business:

Please describe your business here:

Owners / Partner / Officers

List all Owners and Partners

Name

Date of Birth

Title

Ownership %

List additional owners by clicking the "+" icon to your right.

Payroll Information

List Payroll Information

Class Codes

Employee Duties

Annual Payroll ($)

Hourly Wage ($)

List additional details by clicking the "+" icon to your right.

General Information

Do you offer safety programs?

Do offer health benefits to majority of employees?

Do employ any minors (under 18)?

Is operation all/part of existing business that was purchased/acquired?

Do you use subcontractors?

Use any equipment that bends/shapes/forms?

Are athletic teams sponsored?

Been a lapse in coverage during past 12 months?

Any work above 15 feet?

Had a bankruptcy in past 7 years?

Are a member of any trade organizations?

Comments

Any additional comments or information that might be helpful in your quote

Disclaimer: No coverage of any kind is bound or implied by submitting information via this online form.

Information from you and other sources, such as your driving, claims, and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties except for insurance underwriting purposes.

This field is for validation purposes and should be left unchanged.