NAI Quick On-Line P&GL Quote Form

This Form may be used Three ways:

1. (Preferred Method) Fill-out form on-line and "Submit" the form via email at the bottom of the page.
2. Fill-out form on-line, print and FAX using a conventional Fax machine.
FAX TO:1-256-764-3017
3. Fill-out form on-line, drop your Internet connection with the form visible and FAX using your Printers FAX option. FAX TO:1-256-764-3017



Agency:                
Agent's Name:          
Agent's Phone No:      
Agent's FAX:           
Agent's Email Address: 
Insured:               
Producer/CSR:             
Quote Needed By:
Applicant Name:         
City:                   
State:  ZIP Code:
County:                  Inside City : Yes No
Occupancy / Operations: 
Loss History:

Years In Business:       Years Of Experience: 
Present/Prior Carrier:  
 Property General Liability
Building Limit:   Payroll:        
Contents Limit:   Receipts:       
Construction:     Area:           
Protection Class: Type Ownership: 
Square Footage:  
Central Station Alarm  Limits Desired
Fire:            Yes  No Limits: 
Burglar:         Yes  No
Ansul:           Yes  No
Age of Building 
Building Update (Years)
 
(If Over 20 Years Old)
Doubled Aggregate:  Yes  No
Wiring:   
Plumbing: 
Contractor Supplement
Roof:      # Owners:    
Coverages Desired # Employees: 
Perils:    Type/s of Work
(basic, Broad, Special)
Type 1: 
Recovery Basis:  Type 2: 
(ACV, or RC)
Type 3: 
Deductible: 
Day Care Supplement
# Of Children: 
General Comments:

IMPORTANT: PLEASE PRINT THIS FORM FOR YOUR RECORDS BEFORE SUBMITTING.