Commercial Insurance
All Fields Marked(*) are Required
Personal Information

First Name: *
Last Name: *
Middle Initial:
Company:*
E-Mail:*
Home Phone:
Work Phone:
Cell Phone:
FEIN or Social Security Number:*
At least one phone number is required (*)

Mailing Address
Address:*
 
City:*
State:*
Postal Code: *

Commercial General Liability & Workers' Compensation

Sections (Please check all that apply)*
Installation/Builders Risk:
Commercial General Liability:
Workers Compensation:

General Information

Please explain all "YES" answers on the remarks section below.
 
1. Is the applicant a subsidary of another entity?* Yes No
 
 
2. Does the applicant have any subsidaries?* Yes No
 
 
3. Is a formal safety program in operation?* Yes No
 
 
4. Any exposure to flammables, explosives, chemicals?* Yes No
 
 
5. Any catastrophe exposures?* Yes No
 
 
6. Any other insurance with this company or being submitted? * Yes No
 
 
7. Any policy or coverage declined, cancelled or non-renewed
during the prior 3 years? *
Yes No
 
 
8. Any past losses or claims relating to sexual abuse or molestation
allegations, discrimination or negligent hiring?*
Yes No
 
 

9. During the last five years, has any applicant been
convicted of any degree of the crime of arson? *

Yes No
 
 
10. Any uncorrected fire code violations?* Yes No
 
 
11. Any bankruptcies, tax, or credit liens against the applicant in the last five years. * Yes No
 
 
12. Has business been placed in a trust?*
(If yes, please state the name of trust below)
Yes No
 
 
Remarks

Current Insurance Carrier and Coverage

Category
Liability 1
Liability 2
Liability 3
Carrier:*
Policy number:*
Retro Date:*
Effective-Exp Date:*
Limits
General Aggregate:
Each Occurrence:
Medical Expense:
Bodily Injury
Occurrence:
Bodily Injury
Aggregate:
Property Damage
Occurrence:
Property Damage
Aggregate:

5 Years of Loss History

 
Date of
Occurrence
Description of
occurrence or claim
Date of Claim Amount Paid
Status
1
2
3
4



 

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