16 - Business Quote Request - Howley Insurance

Request a Quote for Business Insurance from
Daniel Howley Insurance Agency

CONTACT DATA
Business Name *
Contact First Name *
Contact Last Name *
Address *
Address 2
City *
State *
Zip Code *
Daytime Phone Daytime Phone - ### - ### ####
Fax Fax - ### - ### ####
Email *
Best Time to Contact You?
CCOVERAGES DESIRED
Desired Limits (Each Occurrence / General Aggregate)

Desired Limits (Each Occurrence / General Aggregate) $300,000 / $600,000 $500,000 / $1,000,000 $1,000,000 / $2,000,000
What % of gross receipts/revenue is derived from serice and/or installation of products?
What % of gross receipts/revenue is derived from the rental of any equipment?
Please indicate whether any of the folowing optional coverages are desired.

The limits provided will be the same as indicated above
Employee Benefits Liability
Hired and Non-Owned Auto Liability
Please indicate whether the following exclusion are desired
General Liability Enhancement Endorsement

Adds additional insureds and other broadening coverages
General Liability Extended Enhancement Endorsement

Add 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?
Additional Comments
TERMS & CONDITIONS

By submitting this form, you are acknowledging your acceptance and understanding of the following terms:

We value your privacy and have made every attempt to protect it. We will not provide your data to any third party for any purpose other than insurance underwriting purposes. By submitting this form, you agree to release us from any liability in the event that this information is accidentally viewed by others.

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

Information from you and other sources such as your credit, driving, claims and insurance histories, may be used to calculate an accurate rate for your insurance.

If you do not agree to all the above terms, please do not submit this form.
Acceptance *

Acceptance Yes I agree
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16 - Business Quote Request - Howley Insurance

16 - Business Quote Request - Howley Insurance

CONTACT DATA

CCOVERAGES DESIRED

Please indicate whether any of the folowing optional coverages are desired.

Please indicate whether the following exclusion are desired

WHOLESALE APPLICANTS ONLY

TERMS & CONDITIONS