COMMERCIAL GENERAL LIABILITY
Applicant Information
Full Name
*
Business Name (if Applicable)
FEIN (if applicable):
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Website (if applicable)
Business Details
Type of Business Entity
*
Please Select
Sole Proprietorship
Partnership
LLC
Corporation
Nonprofit
Industry / Type of Business
Business Description: (Briefly describe your products/services and operations)
*
Years in business or years of experience?
*
Annual Revenue: (Or expected revenue)
*
Number of Employees:
Coverage Information
Do you currently have General Liability Insurance?
Please Select
YES
NO
Current Insurance Provider:
Policy Details
Please upload copy of current policy.
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Requested Coverage Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Coverage Limits
*
Rows
(example $1,000,000)
Per Occurance
Aggregate
Deductible Preference:
Business Location & Operations
Do you own or lease your business premises?
*
Please Select
Own
Lease
Number of Locations:
Additional Location Addresses and Square Footage
Square Footage of Primary Premises
*
Are hazardous materials used or stored on-site?
Please Select
YES
NO
Describe Hazardous Materials:
Risk Assessment
Have you had any claims in the past 5 years?
*
Please Select
YES
NO
Claim Details: (brief description to include dates, type and amount paid)
Do you perform work or services outside your primary business location?
*
Please Select
YES
NO
Describe Work or Services:
Do you work with Subcontractors?
*
Please Select
YES
NO
Do subcontractors carry their own insurance?
Please Select
YES
NO
Do you require additional insured endorsements?
Please Select
YES
NO
Names and Relationships of Additional Insured Parties:
Are there specific contracts or clients requiring this insurance?
Please Select
YES
NO
Provide Details:
Do you require other business insurance coverage?
Commercial Property
Commercial Auto
Workers' Compensation
Professional Liability
Other
Preferred Payment Method
Please Select
ANNUAL
PAYMENT PLAN (may incur interest %)
Submit
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