FBU General Liability Submission

FBU General Liability Submission
Agency*
Email Address*
example@example.com
Line of Business*
What type of contractor is your applicant?*
Does the applicant hire subcontractors to work on their behalf?*

YesNo
Applicant Information
Name Insured*
Insured DBA (if applicable)
Insured Entity Type*
Contractor Information
Please describe the applicant's business operations*
Does the applicant have a website or online business listing (Facebook, Yelp, Google, etc)?*

YesNo
In what states does the applicant have operations? (Hold CTRL to select multiple states)*
In what year was the applicant's business founded?*
Is this a new venture where coverage starts the day of business inception?*

YesNo
Projected annual revenue for next 12 months
Total number of active owners*
Total number of full time employees (not including owners)*
Total number of part time employees (not including owners)*
Employee Payroll
Is the applicant licensed for all work performed?*

YesNo
Has the applicant had any General Liability losses in the last five (5) years?*

YesNo
Has the applicant had prior coverage canceled or non-renewed?*

YesNo
Does the applicant operate any other businesses besides this one?*

YesNo
Has the applicant been in business more than 12 months with no prior insurance coverage or a lapse in coverage?*

YesNo
Coverage Details
Requested Effective Date*

MonthDayYear
Date
Requested Occurence/General Aggregate Limit*
Should be Empty:

Applicant Information