Harris County Insurance

Baytown Agency
608 Rollingbrook Drive
Baytown, Texas 77521
(281) 427-6511
Pasadena Agency
825 Southmore Ave
Suite 202
Pasadena, Texas 77502
(713) 481-0700
Houston Metro Agency
4221 Telephone Road
Houston, Texas 77087
(832) 500-3666
(713) 641-1234
Houston Agency
13030 Woodforest Blvd
Suite C
Houston, Texas 77015
(832) 582-8500

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BUSINESS OWNERS PROGRAM
General Liabilty Quote Request

1
Contact Information
Contact Name:
Name of Business
Address:
Address 2:
City - St - Zip:
Phone Number:       FAX
E-Mail Address:
2
Desired Limits: Each Occurrence / General Aggregate (other limits may be available upon request)
$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000    
3
What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?
4
What percentage, if any, of gross receipts/revenues is derived from the rental of equipment?
5
Are any of the following optional coverages desired? (The limits provided will be the same as the limits chosen in above).
  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
6

Are any of the following exclusions desired?

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
Following Section for Wholesale Applicants ONLY
7
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? $
8
Do you do any repackaging, re-labeling, repair or re-manufacturing of products?
YES NO
Hit the Submit Button to send your Quote Request. We will get back to you with your free, no obligation quote as soon as possible.

AGENCY LICENSE # 3664
Copyright @ 2007 Harris County Insurance Center - All Rights Reserved
Offices in Houston, Baytown, and Pasadena Texas.
Note: As stated in our "Terms of Service" (TOS) agreement, descriptions of insurance coverage on this web site are for informational purposes only and may not apply, or be included on your policy. Please contact us to confirm coverage provided on your insurance policy or policies your are contemplating purchasing.