Gregory Marine Insurance

Commercial Insurance

All Fields Marked(*) are Required

Personal Information

Home Phone:
Work Phone:
Cell Phone:
FEIN or Social Security Number:*
At least one phone number is required (*)

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

5 Years of Loss History

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