General Liability Quote Request | JF Wealth Strategies

1 · Business 2 · Coverage 3 · Exposures 4 · Prior & Losses 5 · Questionnaire 6 · Submit

Prefer to fill it out by hand? Download the PDF version → and email it to jason@jfwealthstrategies.com.

Business Information

Named Insured (Legal Business Name)*

FEIN #*

Year Business Started

Renewal / Effective Date

Mailing Address (Street)

City

State

ZIP

Contact Name*

Phone*

Email*

Type of Organization

Description of Business Operations / Products & Services*

Classification, Payroll & Officers

Class codes & payroll are the biggest driver of your premium. If you don't know a code, just describe the job and we'll classify it.

Employers Liability Limits

Experience Mod (if applicable)

Class Codes & Annual Payroll

Officers / Owners

Coverage Election

Officer Names & Duties (list all)

Operating Location

Complete only if your operating location is different from the mailing address above.

Location Address (Street, City, ZIP)

Operations Detail

Radius of Operations

Any Roofing?

Max Height Worked

If a new venture — prior experience in this operation (employer & # of years)

Prior Coverage & Loss History

3-year loss runs are required to bind coverage. Prior loss detail helps us get you the best pricing.

Prior Carrier

Expiring Annual Premium ($)

Prior Losses — Last 3 Years

Underwriting Questionnaire

Answer each Yes or No. Explain any 'Yes' responses in the notes box at the bottom.

Notes — explain all 'Yes' responses

Review & Submit

Confirm below and submit. We'll begin shopping your coverage and follow up within one business day.

Questions first? Book a call →

Request received — thank you.

We'll start shopping your workers' comp coverage and reach out within one business day. To bind, we'll need 3-year loss runs. Questions? Call (951) 405-2020.