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Johns Insurance Agency
2223 Blue Heron Loop
Lincoln, CA 95648

Phone:
Fax:
Email:
CA Lic. #:

(626) 826-4080
(888) 239-2506
info@johnsinsurance.com
0589663

Request information on
a product or service

Get a quote on your
business insurance needs

Product Liability Insurance Quote

We would like to provide you with a free, no-obligation product liability insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Business:
Contact Name:
Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
Contact Email Address:
Company or Product Website:	http://www.

Current Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $

About Your Business
# of full-time employees	# of part-time employees	How long in business	How many locations	Annual sales
		years		$
Please give a brief description of your business and clientel (below):

Products And Operations

Please provide info for those products and/or services you need coverage for.

Products and Services
(or specific categories)

Applicant Acts as a(n)

#
of
Yrs

% of
Gross
Rcpts

Does
Applicant

Products sold to:

Mfr.

Whole-
saler

Retail-
er

Import-
er

Mfr.
Rep.

Install
?

Repair
or Svc?

Whole-
saler

Retail-
er

Con-
sumer
Direct

Other

Product Liability Insurance Coverage(s)
Please list the type of coverage(s) you are interested in (below):


Do you require fire & theft coverage?:				Yes No

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have
additional information where there was not enough space, please enter them here.

Please click on the "Submit Form" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states. For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.