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Comprehensive General Liability - Request Quote
Comprehensive General Liability Form
COMPANY INFORMATION
      Your Name: 
   Company Name: 
 Postal Address: 
           City:   State:  ZIP: 

 Effective Date: 
Expiration Date:
COVERAGES
DEDUCTIBLES
Property Damage   
Bodily Damage     

Per Claim    Per Occurrence
LIMITS 
                         General Aggregate   
 Products & Completed Operations Aggregate   
             Personal & Advertising Injury   
                           Each Occurrence   
                Fire Damage (Any one fire)   
          Medical Expense (Any one person)   

Other Coverages, Restrictions And/Or Endorsements

SCHEDULE OF HAZARDS
LOCATION # DESCRIPTION OF OPERATION PREMIUM BASIS
ANNUAL PAYROLL


ANNUAL SALES
ANNUAL PAYROLL


ANNUAL SALES
ANNUAL PAYROLL


ANNUAL SALES
ANNUAL PAYROLL


ANNUAL SALES
CONTRACTORS (Explain all "yes" responses for past or present operations)
1. Does applicant draw plans, designs, or specifications?

2. Do any operations include blasting or utilize or store explosive material?

3. Do any operations include excavation, tunneling, underground work or earth moving?

4. Do your subcontractors carry cover ages or limits less than yours?

5. Are subcontractors allowed to work w/o cert of ins?

6. Does applicant lease equipment to others with or without operators? 
 % Of Work Subcontracted: 
       # Full Time Staff: 
       # Part Time Staff: 

Remarks / Describe the Type Of Work Subcontracted:
PRODUCTS/COMPLETED OPERATIONS
PRODUCTS ANNUAL GROSS SALES

Explain all "yes" responses (for any past or present product or operation)

1. Does applicant install, service, or demonstrate products?

2. Foreign products sold, distributed, used as components?

3. Research and development conducted or new products planned?

4. Guarantees, warranties, hold harmless agreements?

5. Products related to aircraft/space industry?

6. Products recalled, discontinued, changed?

7. Products of others sold or re-packaged under applicant label?

8. Products under label of others?

9. Vendors coverage required?

10. Does any named insured sell to other named insureds?

Please Send Copies Of Literature, Brochures, Labels, Warnings, Etc.
GENERAL INFORMATION
1. Any medical facilities provided or medical professionals employed or contracted?

2. Any exposure to radioactive/nuclear materials?

3. Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc)

4. Any operations sold, acquired, or discontinued in last 5 years?

5. Machinery or equipment loaned or rented to others?

6. Any watercraft, docks, foats owned, hired or leased?

7. Any parking facilities owned/rented?

8. Is a fee charged for parking?

9. Recreation facilitied provided?

10. Is there a swimming pool on the premises?

11. Sporting or social events sponsored?

12. Any structural alterations contemplated?

13. Any demolition exposure contemplated?

14. Has applicant been active in or is currently active in joint ventures?

15. Do you lease employees to or from other employers?

16. Is there a labor interchange with any other business or subsidiaries?

17. Are day care facilities operated or controlled?

REMARKS:
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