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E-Mail:
info@fivestar
insuranceagency.com

Toll-Free Phone:
1-866-740-4132

Local Phone:
1-678-526-7979

Fax Number:
1-678-526-7222

Office Address:
2093 Rock Chapel Road
Lithonia, GA 30058

Five Star Insurance Agency

Owned and Operated by:
Aisha Smith-Danzy
Since 2006

Proudly Representing:

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Ins. Web Sales, Inc.


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On-Line Contractor
General Liability Quote Form
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BUSINESS Name:
Mailing Address:
City:
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Zip/Postal:
E-Mail (REQUIRED):
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Phone:
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Business Underwriting Information
Type of operation:
Describe operations in detail:
License class:
License Number:
 
Limit of Liability
Coverage Requested?		 $300,000
$500,000
$1 Million
 
Currently Insured? Yes No
Name of Carrier & how long insured?
Prior Claims? Yes No
Describe claims in detail:
 
Years in business:
Years experience in field:
Percentage of work residential:
Percentage of work commercial:
 
Number of Active Owners:
Number of Employees: 0   1   2   3+
Annual Employee Payroll: $
Annual Gross Sales: $
 
Do you subcontract work? Yes No
(If yes, what percentage of your work
is subbed, and what kind of work?)
Do you do foundation work? Yes No
Do you work on condos? Yes No
Employees paid over $18/hour? Yes No
Do you have a safety program? Yes No

 
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