General Liability Form

Owners Names:

Address (mailing):

City& Zip:

**SS# or Fein#

Web Address/e-mail: 

Description of business in detail:

Is business: Corporation Partnership Individual

or

prior experience:

Current Insurance Carrier

Current Premium

Has any business policy been cancelled, or non-renewed in the last three years? Yes No

Any claims in the last three years? Yes No

If yes, please describe:

**Address of each location: (Physical Location)

Limits of general liability

Do you need an umbrella? Yes No If yes, Limit desired   

***MUST HAVE THIS INFO

Number of employees

Estimated payroll for this year

Estimated payroll for next year

Estimated receipts for this year

Estimated receipts for next year $

Percentage of work

Residential %

Commercial %

Subcontracting %

Cost of Subs $

Optional Coverages

Money and Securities Limit on premises, off premises

Accounts Receivable Limit

Employee Dishonesty Limit

When Are deposits made? Daily Weekly Monthly

Is money kept in safe? Yes No If no, where is money kept?

Employee benefit liability? Yes No If yes, what limit?   

Professional Liability

Liability Limits Ded   or Retention limit

Current Carrier

Effective dates to

to

Business policy annual premium

Home Owners Association

# of Homes, Condos, Townhouses

# of people on the board

Is there a pool? If yes, how deep is gate self-locking? rules posted? fenced?
how high is the fence? Playground? If yes, what type of equipment?

Restaurant Coverage:

Type of fire suppression system: Ansel Water other : explain other:

Is there a bar? If yes, is it separated from the restaurant? Seating of the bar

Type of Liquor License

Sq. footage open to the public

Is there smoking? how are the ashtrays and contents handled? Are trays emptied in a metal container?

Auto garages

# of bays Number of lifts what kind of lock on the lift