General Liability Insurance Quote

Thank you for your interest in receiving a quote from Nepa Insurance Agency. This form should only take about 5-10 minutes to complete. Don’t worry if you don’t have everything. You can always click the “Save and continue later” button below. We’ll email you a private link to pick up where you left off.

When do you want your policy to start?

What kind of business do you operate?

Sub Category

Which type of insurance are you looking for?

Commercial Property

Commercial Vehicles

General Liability

Workers Compensation

Builders Risk

Professional Liability

How were you referred to us?

Business Information

Legal Business Name

Entity Type

DBA

FEIN

Website

Business Address

City

ZIP

State

Work Phone

Year Business Started

Years operating this business?

Years experience in this field?

If less than 3 years experience, explain your prior experience and any Specialized Training or Certification

Primary Business Contact

First Name

Last Name

Primary Insured: Date of Birth

Mobile Phone

Additional Business Owners

If there are multiple owners of the business, enter their information below. Otherwise you may skip this section.

Additional Owners List

Owner Name

Company Role

Phone

Business Information Continued

What is your total annual sales/revenue? (Gross)

Do you have employee(s)?

Yes

Number of employees

Estimated annual payroll

Do you lease your employees?

Yes

Owner payroll

Do you use any subcontractors? (1099s)

Yes

Number of subcontractors

Subcontractor annual payroll

What type of work do your subs perform?

Do you have a written contract with your subs requiring them to name your business as Additional Insured and show proof every year?

Yes

Not Yet

Are all subcontractors required to sing a hold harmless and indemnification agreement in your favor?

Yes

Not Yet

Building and Property Information

My business location is

Leased Property

Owned Property

Work From Home

Do you need property coverage for the building?

Yes

Have you made any tenant improvements?

Yes

In the future

How much tenant improvement coverage do you need?

Square footage of your business

Do you have more than 1 business location?

Yes

Do you have more than 1 business location?

Location Address

Street Address

State

Zip

Square Feet

Location is

Additional Business Property Coverages

If you want coverage for any of the areas below please indicate the amount of coverage needed. Otherwise you may skip this section.

Inventory / Stock Amount

Computer Equipment Amount

Loss of Income Amount

Portable Equipment Amount

Text InputLoss of Rent Amount

Business Description

Please describe the nature of your business

Please be descriptive as this will prevent additional underwriting questions and delays.

Manufacturing

Is there any manufacturing, mixing, re-labeling, or repackaging of products?

Yes

Please describe

Liability Limits (optional)

What is the Liability limit requested?

Do you need any Business Personal Property coverage?

Yes

Not sure, let's discuss

Are you interested in Loss of Use / Business Income coverage?

Yes

Not sure, let's discuss

Additional Insured Information (optional)

Do you have anyone that needs to be listed as Additional Insured?

Yes

Additional Insured Information. (i.e. Name & Address)

Additional Insured Document(s)

Choose File

Claims Information

Have you had any claims or losses in the last 5 years?

Yes

What was the date, amount paid, and description of each loss or claim

Has your business been cancelled or non-renewed in the last 4 years?

Yes

Have you ever filed for bankruptcy?

Yes

Bankruptcy: Please describe when and why

Do you have ANY business insurance currently?

Yes

Current Insurance

Name of current insurance carrier?

Expiration date of current policy

Current total insurance premium?

File Upload

Choose File

Do you have ANY previous business insurance from the past 3 years?

Yes

Prior Insurance

Please enter your prior business insurance information below.

Prior Carrier Name 1

Policy Year 1

Premium 1

Additional Comments and/or Documents (optional)

Any additional comments

Any Additional Documents

Choose File

Wrapping Up

Consent

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge.

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Customized coverage for all types of businesses, large and small.

Commercial Property

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