COMMERCIAL GENERAL LIABILITY APPLICATION/ SURVEY

Broker:
Name of Insured:
Address of Insured:
Principals:
No. Of Years in Business:	Licensed as: (applicable to contractors)
Description of Operations:
If new Company/ Operation- Describe work experience of the principals:
Estimate Payroll: Note: If “Off Premises” operations are applicable, give amount and description:
Percentage of construction work which is: a) Residential: % b) Commercial: % c) Industrial: %
Work sublet? Yes No If yes: Amount $ Description:
Are subs insured? Yes No If yes, what limit is requested? Cert. of insured obtained? Yes No
Estimated annual sales or receipts: $ If more than one operation/ product give $ or % breakdown per category:
Are there any ‘Off premises’ welding or cutting operations? Yes No If yes, give ($ or %):
Sales to U.S.A? Yes No If yes, Amount $
Description:
Area: sq ft # of suites: # of elevators: Pool? Sauna?
Other hazards:
Is there any Third Party Fire Property Damage exposure with respect to insured premises (ie: Adjacent Buildings, etc.) Yes No
If yes, Describe:
Previous Insurer: Policy #: Deductible:
Claims experience: Describe all liability losses, paid or reserved over the past 3 years:
Coverage: Bound Not Bound Effective Date: Limit Required? Deductible?
Frills required:
Has any Insurer cancelled, declined or refused to renew or issue insurance of the type applied for? Yes No
If yes, give reason: