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GENERAL LIABILITY INSURANCE QUOTE APPLICATION
Fields marked (*) are mandatory.
General Information
Name of Business*
Inspection Contact Name*
Mailing Address*
City*
State*
Zip*
Location Address*
City*
State*
Zip*
Business Phone
Fax
Contact Email Address
Business Status
Years in Business
Current Insurance Information
Company Name (not agency)
Premium
Effective Date
 
Expiration Date
 
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:
Premium
Carrier Name
Premium
Project/Work Information
Pease write a Description of Operations
What percentage of your work is (each line must total 100%)
Commercial (%)
Industrial (%)
Residential (%)
New Construction (%)
Remodel/Additions (%)
What percentage of your work is as a
General Contractor (%)
Subcontractor (%)
What percentage of your work is
Sub contracted Out (%)
Sub Costs ($)
Do you collect certificates of insurance at a $1,000,000 limit?
Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years and the next 12 months
(3rd yr prior) $
(2nd yr prior) $
(Last 12 mths) $
(Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising
Payroll of employees excluding owners, officers, partners & clerical ($)
Dollar value of average job completed incl. all materials, lab or & equipment ($)
describe any projects) underway or planned for the next year, including values

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?
Have you ever been named in litigation regarding faulty construction?
Are there any claims or legal actions pending?
Do any of the entities name din the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or propert

Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential
Claim #1
Claim Status:
Date of Occurrence
 
Date of Claim
 
Type/Description of Occurrence or Claim
Amount paid on your behalf:
Amount reserved on behalf:
Claim #2
Claim Status:
Date of Occurrence
 
Date of Claim
 
Type/Description of Occurrence or Claim
Amount paid on your behalf:
Amount reserved on behalf:

Additional Comments
Please give any additional comments you feel appropriatefor this quotation.
 

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