AMR Insurance - Tacoma, Washington - Professional Liability Quote

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Name of Business
Contact Name:
Address:
Mailing Address:
City, State, Zip
Phone Number	Home Work
Email
Location for this quote.(Address)

Employee Benefits Liability	YES NO
Liquor Liability	YES NO
If yes, please provide annual Liquor Receipts $
Hired and Non-owned Auto Liability	YES NO
Stop Gap Liability (ND, OH, WA, WV and WY only)	YES NO
Limited International General Liability Extension Endorsement	YES NO

a) General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages).
YES NO
b) General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages).
YES NO

Are all goods manufactured domestically or by a company with a location in the US?	YES NO
If no, is Imported Products Liability Coverage desired?	YES NO
If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products? $
Do you do any repackaging, re-labeling, repair or re-manufacturing of products?	YES NO

Professional Liability Quote

Contact Information

Questions

Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above).

Please indicate whether any of the following exclusions are desired.

Wholesale Applicants ONLY

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