Texas Liability Insurance Form

Business Information

Business Name

Address

City, State, Zip AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Contact Name

Phone No. Ext Fax No.

Email Address Federal Employer's ID #

Years in Business

Description of Operations or SIC code

Estimated Annual Payroll: $ Gross Sales: $

Select all that apply to your Texas business Operate or lease aircraft/watercraft Work Underground Work above 15 feet

Require out of state travel Use Subcontractors Delivery Service

Pre-employment physicals Offer safety incentive programs

Store, treat, dispose, or transport hazardour waste

Work on vessels, docks, or bridges over water Other

Recent Insurance Information

Current Insurance Company Policy Expiration Date

What types of coverages do you currently have? Benefit Liability Business Liability Commercial Umbrella

Directors & Officers Liability Discrimination Errors & Omissions

Product Liability Professional Liability Other

Other Insurance Company Used Within Past 3 Years

Losses past 3 years Select Yes No Amount paid for each loss: $

Description of losses or loss runs

Choose Texas Business Liability Insurance Limits

General Aggregate Limit (other than products completed) Select None $300,000/$300,000 $300,000/$600,000 $500,000/$500,000 $500,000/$1 million $1 million/$1 million $1 million/$2 million

Products/Completed Operations Aggregate Limit Select None $300,000/$300,000 $300,000/$600,000 $500,000/$500,000 $500,000/$1 million $1 million/$1 million $1 million/$2 million

Umbrella Amount Select None $1 million $2 million $3 million $4 million $5 million

Property Information

Building Value $ Contents Value $

Total Building Area Year Built

Construction Type Select Wood Frame Steel Reinforced Mill Concrete Block Concrete Tilt Up Sprinklers Select Yes No

Electrical Type Electrical Renovation Year Amps

Plumbing Renovation Select None Partial Complete Plumbing Renovation Year

Heating Type Heating Renovation Year

Roofing Renovation Select Partial Complete Roof Age (years)

Burglar Alarm Select Yes No Central Station Alarm Select Yes No

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