Dunn & Associates Insurance, Inc.
Skip Links and Proceed to Page Content
Home :  About :  Staff :  Personal Coverages :  Business Coverages :   Financial Coverages :  Employee Benefits : 
Individual Life & Health : Contact


Please complete the following form, and hit the Submit button.
We will contact you as soon as possible.

General Liability Form



Personal Information
Name of Insured: 
Name of Business: 
Address: 
City:    State:    Zip: 
Day Phone:    Night Phone: 
Email Address: 
Employees (inc. owners) 

Business Information
Sole Proprietor:     Partnership:    Corporation:
Limits of Liability:  100,000 300,000 500,000 1,000,000
Est. Annual Payroll:    Est. Gross: 
New Business?  Y N
Years in Business:    Years Experience: 
Business Location:   Mainland   Beachside  
If New Business Previous  Employer: 
Prior Insurance if Existing  Business: 
How Many Years with  Company?    Expiration Date: 
Exclusion Needed?  Y N
If so, full name: 
Social Security Number:    Date of Birth: 

Workers Compensation
# of Employees:  
Corporate Officers & Owners:   Included? Excluded?
Please give a job description for each class of employee, and the payroll amount for that class.
Payroll Amount: $ 
Please give a job description for each class of employee, and the payroll amount for that class.
Payroll Amount: $ 
Please give a job description for each class of employee, and the payroll amount for that class.
Payroll Amount: $ 

Miscellaneous
 Please select any of the following in which you may be interested. If you check  the box, please fill out the information that follows.
Glass Coverage:     # Plates: Sq.Feet: Size(inches):
Sign Coverage:     Type: Free Standing: Attached to Building:
Employee Dishonesty           Hired & Non-Owned Autos
Mini-Computer                     Loss of Income

Additional Comments
Please make any additional comments you feel necessary for this quotation. If you have additional information where there was not enough room, please enter it here.
(Audio)
Reload image if not clear

Enter letters/numbers below




Home :  About :  Staff :  Personal Coverages :  Business Coverages :   Financial Coverages :  Employee Benefits : 
Individual Life & Health : Contact


Dunn & Associates Insurance, Inc.

Phone: (386) 255-2477

324 W. International Speedway Blvd.

Fax: (386) 255-3573

Daytona Beach, FL 32114-4289

Email: info@dunn-insurance.com

© Dunn & Associates Insurance, Inc.