Commercial General Liability (CGL)
Primary Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Information
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Type/Industry
*
Years in Business
Number of Employees
Annual Revenue
*
Business Entity Type
*
Sole Proprietorship
Partnership
Corporation
LLC
Other
Current Insurance
Do you have current CGL insurance?
*
Yes
No
Current Insurance Carrier
*
Current Policy Expiration Date
*
-
Month
-
Day
Year
Date
Coverage Limits
General Aggregate Limit
*
$1,000,000
$2,000,000
$3,000,000
Custom
Per Occurrence Limit
*
$500,000
$1,000,000
$2,000,000
Custom
Medical Payments Coverage (per person)
*
$5,000
$10,000
$25,000
Waive this coverage
Products-Completed Operations Aggregate
*
$1,000,000
$2,000,000
Custom
Deductibles
General Liability Deductible
*
$0
$500
$1,000
$2,500
Custom
Premises and Operations
Describe Business Operations
*
Do you own or lease the business premises?
*
Own
Lease
Are subcontractors used?
*
Yes
No
Do you require subcontractors to carry their own insurance?
*
Yes
No
Do you conduct operations at customer locations?
*
Yes
No
Additional Coverages/Endorsements
Hired and Non-Owned Auto Liability
*
Yes
No
Employee Benefits Liability
*
Yes
No
Cyber Liability Coverage
*
Yes
No
Employment Practices Liability
*
Yes
No
Directors and Officers Liability
*
Yes
No
Umbrella/Excess Liability
*
Yes
No
Claims History
Have there been any general liability claims in the past 5 years?
*
Yes
No
Please describe the claims and outcomes
*
Additional Information
Submit
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