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On-Line Commercial General
Liability Insurance Quote Form
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Your Personal Data

Your Name:
Business Name:
Property Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Underwriting Information
 
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
 
Business Contents Needed?
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Comments/Remarks:
 
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For Insurance Information contact the Short Insurance Group at:
www.shortinsurancegroup.com    Mailing Address:   PO Box 70696   Albany, GA 31708
Office Address:   1579 U.S. Hwy. 19 South     Leesburg, GA 31763
E-Mail Questions or Service Needs at: service@shortinsurancegroup.com
Please Contact Us At Our Toll Free Phone Number: 888-883-2928
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