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   Triglobal Insurance

   PO Box 984

   Danville, CA 94526

   CA Ins. License# 0D65257

   PHONE: 925-365-3200

   FAX: 925-226-1422

   E-MAIL US AT:
   info@tgionline.info

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Online Contractor General Liability Quote Form
One Simple Form - takes only 2-3 Minutes!
Insurance Agents Name:
Insurance Agents Phone Number:
Your Client's Name:
Your Client's Company Name:
Mailing Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
Social Sec. or Employer ID#:
 
Limit of Liability
Coverage Requested?		 $300,000
$500,000
$1 Million
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
 
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
 
Number of Active Owners:
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $
Annual Gross Sales: $
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

 
Comments/Remarks:
 
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