Emerald - G.R. Klinefelter
Image #

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Quote #


General Quote Form


Policy Holder 1 Policy Holder 2
Name: Name:

Agency:

Status: Effective Date:
Method: Expiration Date: Premium Fully Earned:
Pay Plan: Inception Year: Min Earned Premium: Earned Premium:
Bill To: Location State: Reporting Form Policy: Deposit Premium:
Transaction Remarks:



Liability Coverages

Each Occupancy Aggregate
General Commercial
Owners/Contractors
Basic General
Products/Completed Ops
Fire Legal
Pers/Adv Injury
Per Person
Med Pay

Products/Completed Operations Premium: MP
Prem Bases Type: Rate:
Additional Fire Legal Premium: MP
Additional Med Pay Premium: MP
Independent Contractors Premium: MP
Prem Bases Type: Rate:



Premises Liability

Location Information
Street Number: Street Name:
PO Box: Zip Code:
City: County: State:
Other Info:

Building Information Occupancy:

Liability Cases by Building Prem: MP
Prem Bases Type: Rate:



Property Cases by Building Prem: Repl. Cost
Coverage: Coinsurance: Limit:
Wind/Hail Deductible: Deductible: Protection:
Cause of Loss Options: Exclusions:



Optional Coverages

Location
Coverages Loc
Lvl


Forms




Additional Interests

Additional Interests Information

Type

Name 1
Name 2
Tax ID
Phone
Email
Description:
Loan Number ATIMA ISAOA
Street Number
Street
Apt/Suite#
P.O. Box
Other Info
City
County
Zip

Policy Summary

General Information
Applicant Name:
Effective Date: Expiration Date:
Transaction Date:
Full Term Premium: Written Premium: Change in Premium:
Pay Plan: Transaction Remarks:

Locations
No. Address Location Premium
Liability
Coverage E - Limits of Liability
Each Occurence Aggregate Premium
General Commercial Liability Insurance:
Owners/Contractors Liability Insurance:
Basic General Liability Insurance:
Products/Completed Operations Liability Insurance:

Fire Legal Liability:

Personal Injury/Advertising Injury:

Coverage F - Limits of Liability
Per Person
Premises Medical Payments Insurance:

None