Vendor Insurance and Producer Insurance | Campbell Risk Management

Have you had this type of policy with Campbell Risk Management in the last 12 months? *

Yes

No

Requested policy effective date *

Policy end date *

Estimated gross annual sales *

Up to $25,000

$25,001 - $100,000

Over $100,000: We will contact you with a customized price quote

Choose your limits of insurance *

$1,000,000 per occurrence / $2,000,000 aggregate limit

$2,000,000 per occurrence / $4,000,000 aggregate limit

Policy Holder Information

Contact & Mailing Information

First Name *

Last Name *

Street Address *

Address (Suite, Apt #)

City *

State *

Zip Code *

Business Information

Select Business Type: *

Name of individual or business to be insured (include DBA if applicable) *

Business Email Address *

Phone *

Website/URL (if applicable)

Have you had any liability insurance claims in the past 5 years? *

Yes

No

Please provide claim details

Have there been any recent incidents that could result in a claim? *

Yes

No

Are you in compliance with all County, State, and Federal Food and Safety Regulations? *

Yes

No

Please list types of products sold (if you are making bath or body products please list the ingredients as well): *

Do you sell any of the following? Finished products that are directly imported, herbal remedies, items targeted toward infants, children's toy's or children's furniture, Alcoholic beverages, Tobacco related products including e-cigarettes or smokeless products, Marijuana or products containing THC, Herbal remedies or medicinal products claiming healing properties. *

Yes

No

Total

Total Amount($)

Total

VENDOR / PRODUCER INSURANCE

Policy Holder Information

Contact & Mailing Information

Business Information

Total