GENERAL
					LIABILITY
	Insureds Name:
	DBA Name:
	Mailing Address:
	State:		Select Maryland Pennsylvania Virginia Delaware Washington, DC New Jersey			Zip Code:
	County:
	Description of operations:
	Total # of owners (Do not include their payroll below):
	Breakdown:			Employee				Area
	Exposure			Payroll		Sales		Sq. Foot
	Years in business:
	Years experience:
	# of employees:
	Proposed effective date:
	Liability limits requested:			Select 100,000 / 300,000 300,000 / 600,000 500,000 / 1,000,000 1,000,000 / 2,000,000
	Any Claims past 3 Years:			Select No Claims Claims - see below
	Please provide details:
	Prior Carrier:
	Prior Premium:
	Is there any additional information you would like us to know about this risk:
	Agency Name:
	Agency Address:
	Agency Phone:
	Agency Fax:
	Agency Contact:
	Contact E-Mail Address:
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