General Liability / Contractors Quote Form Ledbetter Insurance Commercial General Liability Insurance Quote Form We would love to hear from you! Please fill out this form and we will get in touch with you shortly. 1 Personal Information2 Underwriting Information Type of BusinessSole ProprietorPartnershipLLCCorporationYour NameBusiness Name:Property Address:City:State:IllinoisIndianaIowaMissouriOhioWisconsinZip/Postal Code:Email:* Phone:Fax (Optional):Number of Years ExperienceNumber of Years in Business Date Coverage Needed: Date Format: MM slash DD slash YYYY Prior Carrier:Describe Business:Gross Annual Receipts:Gross Annual Payroll:Square Footage of Your Business Location:Number of Employees:Prior Claims?YesNoDescribe claims in detail:Limits and CoveragesLiability Limits$100,000$300,000$500,000$1 MillionBusiness tools and/ or equipment needed? If so, list type and amount:Send my quotation via:E-MailFaxRegular MailCall me by PhoneContact InformationName* First Last Position*Best Method of Contact*PhoneEmailTextFaxPhone Number*Best Time to Contact* : HH MM AM PM EmailThis field is for validation purposes and should be left unchanged.
