COMMERCIAL GENERAL LIABILITY SECTION

Applicant / First Name Last Name *

Full Name of Business *

Business Address *

How Many Years in Business *

Estimated Annual Revenue *

FEIN *

Please provide a detailed outline of the work you perform in the field. For example, Residential remodeling, with or without structural framing. Roofing, swimming pool installation, adding square footage, window installation (how many floors), Painting, Plumbing, Excavation (how deep), etc.

Description of Operations

Do you use any subcontractors *

Yes

Subcontractor Annual Cost

Any Claims in the last 3 years *

Yes

Any Bankruptcies in the last 5 years *

Yes

License of Application #

Email *

Phone *

Effective Date *

Date of birth *

Website

By checking this box, I consent to receive non-marketing text messages from [BUSINESS NAME] about [USE_CASE_FROM_CAMPAIGN_DESCRIPTION]. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from [BUSINESS NAME] at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

COVERAGES

COMMERCIAL GENERAL LIABILITY *

CLAIMS MADE

OCCURRENCE

LIMITS

GENERAL AGGREGATE *

EACH OCCURRENCE

MEDICAL EXPENSE (Any one person)

EMPLOYEE BENEFITS

OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)

CLAIMS MADE (Explain all "Yes" responses)

1. PROPOSED RETROACTIVE DATE:

YY-MM-DD

2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:

3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

CONTRACTORS

EXPLAIN ALL "YES" RESPONSES (For all past or present operations)

1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN

3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

DESCRIBE THE TYPE OF WORK SUBCONTRACTED

$ PAID TO SUB- CONTRACTORS

% OF WORKSUBCONTRACTED

PRODUCTS / COMPLETED OPERATIONS

EXPLAIN ALL "YES" RESPONSES (For all past or present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC.

1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

7. PRODUCTS UNDER LABEL OF OTHERS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

8. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

9. VENDORS COVERAGE REQUIRED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

GENERAL INFORMATION

EXPLAIN ALL "YES" RESPONSES (For all past or present operations)

1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, ORTRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

7. ANY PARKING FACILITIES OWNED/RENTED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

8. IS A FEE CHARGED FOR PARKING?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

9. RECREATION FACILITIES PROVIDED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

10. IS THERE A SWIMMING POOL ON THE PREMISES?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

11. SPORTING OR SOCIAL EVENTS SPONSORED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

13. ANY DEMOLITION EXPOSURE CONTEMPLATED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

17. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

18. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .

20. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?

YES

IF YES IS SELECTED IN THE PREVIOUS QUESTION, PLEASE EXPLAIN .