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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 Quick-Quote
Commerical Price Indicator Form
One Simple Form - takes only 2-3 Minutes!
Select All Types of Coverage Needed: Package
Monoline Liability
Monoline Property
Workers Compensation
 
Broker's Name & Phone #:
 
Client Name:
BUSINESS Name:
Mailing Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Website Address, if you have one:
 
Business Underwriting Information
Type of operation:
Describe Operations in Detail:
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Claims in Last 5 Years? 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: $
Location Square Footage
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
 
Liability coverages:
Limit of Liability: $300,000
$500,000
$1 Million
 
 
Property coverages:
Building Coverage: $
Personal Property Coverage: $
Loss of Income: $
Deductible: $500 $1,000
$2,500 $5,000
 

Any comments or other requests/remarks:
 
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