Commercial General Liability
(*New in busines and uses contractors)
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Name (First named Insured & other named insured's)
Name of Contact Person:
DBA (Doing Business As)
Proposed Effective Date:
Mailing Address:
   
Home Telephone: Work Telephone: Fax Telephone:
Email Address:
Business entity:    Year business started:
Number of Employees: Full time(Include Self) Number of Employees: Part time
Premises Information
Address: Street, City, State, Zip
                    
City Limits
Inside
Outside
Interest
Owner
Tenant
Year Built:
Part Occupied
%
Premises Square Feet:     
**********Nature of business/description of operations by premise(s)**********
Please be very descriptive and DO NOT LEAVE BLANK. Click here for HELP
General Information and underwriting questions
1. Is the applicant a subsidiary of another entity of does the applicant have any subsidiaries? Yes No
2. Is a formal safety  program in operation? Yes No
3. Any exposure to flammables, explosives, chemicals? Yes No
4. Any catastrophe exposure? Yes No
5. Any other insurance with this company or being submitted? Yes No
6. any policy of coverage declined, cancelled or non-renewed during the past 3 years? Yes No
7. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Yes No
8. During the last ten years, has any applicant been convicted of any degree of the crime of arson? Yes No
9. Any uncorrected fire code violations? Yes No
10. Any bankruptcies , tax or credit liens against the applicant in the past 5 years? Yes No
11. Has the business been placed in a trust? Yes No
Please explain any Yes answers:

Loss History

Check this box if you have NO losses in the last 4 years:
Lost history information: Please list dates, description of claim, amount paid, and claim status.
Liability Coverage Requested
General Aggregate Liability Coverage Recommended $2,000,000
Products & Completed Operations Aggregate Recommended $1,000,000
Personal & Advertising Injury Recommended $1,000,000
Each occurrence Recommended $1,000,000
Fire damage (any one fire) Recommended $100,000
Medical expense (any one person) Recommended $5,000
Contractor questions (Only) Check this box if you don't use Contractors
1. Does applicant draw plans, designs, or specifications for others? Yes No
2. Do any operations include blasting or utilize or store explosive material? Yes No
3. Do any operations include excavation, tunneling, underground work or earth moving? Yes No
4. Do your subcontractors carry coverage's or limits less than yours? Yes No
5. Are subcontractors allowed to work without providing you with a certificate of insurance? Yes No
6. Does applicant lease equipment to others with or without operators? Yes No
Please describe the type of work subcontracted:
$ Paid to Subcontractors:    % of work Subcontracted:
# of full-time staff:       # of part-time staff:
Product / Completed Operations:
Products
 Annual Gross Sales
$ (or projected sales)		 # of Units
Annual Payroll:   
1. Does applicant install, service or demonstrate products? Yes No
2. Foreign products sold, distributed, used as components? Yes No
3. Research and development conducted or new products planned? Yes No
4. Guarantees, warranties, hold harmless agreements? Yes No
5. Products related to aircraft/space industry? Yes No
6. Products recalled, discontinued, changed? Yes No
7. Products of others sold or re-packaged under applicant label? Yes No
8. Products under label of others? Yes No
9. Vendors coverage required? Yes No
10. Does any named insured sell to other named insured's? Yes No
Explain all "YES" responses
Additional Interest/Certificate Receipt
 Additional Insured  |   Loss payee  |   Mortgagee |    Lien holder  |   Employee as Lessor
Name and Address
Name and Address
General Liability Information
1. Any medical facilities provided or medical professionals employed or contracted?
 Yes No
2. Any exposure to radioactive/nuclear materials? Yes No
3. Do/have past, present or discontinued operations involve(d) storing, treating, discharging,
applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc)		 Yes No
4. Any operations sold, acquired, or discontinued in last 5 years? Yes No
5. Machinery or equipment loaned or rented to others? Yes No
6. Any watercraft, docks, floats owned, hired or leased? Yes No
7. Any parking facilities owned/rented? Yes No
8. Is a fee charged for parking? Yes No
9. Recreation facilities provided? Yes No
10. Is there a swimming pool on the premises? Yes No
11. Sporting or social events sponsored? Yes No
12. Any structural alterations contemplated Yes No
13. Any demolition exposure contemplated? Yes No
14. Has applicant been active in or is currently active in joint ventures? Yes No
15. Do you lease employees to or from other employers? Yes No
16. Is there a labor interchange with any other business or subsidiaries? Yes No
17. Are day care facilities operated or controlled? Yes No
18. Have any crimes occurred or been attempted on your premises within the last three years? Yes No
19. Is there a formal, written safety and security policy in effect? Yes No
20. Does the businesses' promotional literature make any representations about the safety or security of the premises? Yes No
Please explain any Yes answers:
Please let us know the best time to contact you:
IF YOU REQUIRE PROPERTY INSURANCE PLEASE COMPLETE OUR
COMMERICAL PROPERTY COVERAGE REQUEST FORM. 
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.