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E-Mail:
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Local Phone:
1-305-541-1002

Fax Number:
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Office Address:
1241 S.W. 27th Ave.
Miami, FL 33135

E & L Insurance
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Since 1996

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Online Commercial General Liability Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Business Name:
Property Address:
City:
State:	MUST be Florida!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):

Underwriting Information

Primary Policy Holder's Social Security Number or Corporation Federal Tax ID#: (Some carriers use credit history to qualify, this information is REQUIRED)

Date Coverage Needed:

Prior Carrier:

Describe Business:

Gross Annual Receipts:	$

Gross Annual Payroll:	$

Square Footage of Your Business Location:	$

Number of Employees:

Tell us what kind of commercial coverage you are looking for, and why:

Prior Claims?	Yes No
Describe claims in detail:

Limits & Coverages:

Liability Limits: $100,000 $300,000
$500,000 $1 Million

Business Contents Needed?
If so, list type and amount:

Comments/Remarks:

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