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Companies We Represent:

Questions?
We'd Love to
Hear From You.

 
E-mail:
rogerk@kisoh.net

 

23366 Commerce Park,
Suite 200
Beachwood, OH 44122
 
Phone: 1-216-397-5890
Fax: 1-216-464-0095
Toll Free: 866-428-8614

Insurance License #14365

On-Line Product 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 Ohio!
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
product coverage you
are looking for, and why:
 
How long do your products
remain in use or on market?
 
Who manufactures your
product and where?
 
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:
 
Send my quotation via: E-Mail Fax
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