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Commercial General
Fields marked (
*
) are mandatory.
Name of Applicant
*
Mailing Address
*
Proposed Effective Date
F.E.I.N. or SSN
Phone
*
Fax
Email
*
Website address
General Business Information
Inspection Contact Name
Inspection Contact Phone
Accounting Contact Name
Accounting Contact Phone
Number of Years in Business
Date Business Started
Description of Business
Current and Prior Policy Information
Claims/Loss History(5 Years)
Prior Carrier Information (last 5 years)
Carrier Name and Year #1
Carrier Name and Year #2
Carrier Name and Year #3
Carrier Name and Year #4
Carrier Name and Year #5
Property Section
Location Address (If Different from Mailing Address)
Building Limit
Bus. Pers. Property Limit
Loass of Income (annual)
Loss of Rents (annual)
Age of Building
Type of Construction
Type of Roof
Number of Stories
Square Footage
Sprinklered
Right Exposure
Rear Exposure
Left Exposure
Burglar Alarm
Central Station
Local Gong
General Liability Section
Liability Limits
General Aggregate
Products & Completed Operations Aggregate
Personal & Advertising Injury
Each Occurrence
Damage to Rental properties (fire legal)
Medical Expense
Employee benefits
Premium Basis
Payroll
Gross Receipts/Sales
Square Footage
Other Coverages (If Yes Please Fill In the relevant Forms)
Commercial Automobile Insurance
No
Yes
Workers Compensation
No
Yes
Excess Liability/Umbrella
No
Yes
Employment Practices Liability
No
Yes