Clone of Application - General Liability

Payroll information is used as a rating basis for certain General Liability classifications, particularly for contracting and service operations.

	Annual Payroll
What is the annual payroll for Office / Clerical Staff employees?
What is the annual payroll for Field, Service, Sales, or Operational employees?

Annual Sales

	Coverage Amount
What are your company’s total projected gross sales for the next 12 months?

Do you currently have Workers’ Compensation insurance?

NoYes
Has coverage ever been canceled or non-renewed?

NoYes
Do the owners/officers wish to be included or excluded from Workers’ Compensation coverage (where permitted)?

NoYes
Do you use subcontractors or independent contractors?

NoYes

Risk Transfer

Please provide details regarding any subcontracted work. This section helps evaluate liability exposure, contractual risk transfer, and insurance compliance.

	Amount Paid
Total cost paid to subcontractors annually

Do you collect Certificates of WC Insurance from the Subcontractors

NoYes

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