COMMERCIAL LIABILITY APPLICATION

Applicant’s Name (Legal and Operating): Broker: Applicant’s Address: How Long in Business: Principal(s): Licensed as (contractors): Description of Building
Area (sq.ft):	# of Suites:	# of Elevators:	Pool:	Sauna:
Liquor receipts: $	Other hazards:
Is there any Third Party Fire Property Damage exposure with respect to the insured premises (ie: Adjacent Buildings, etc.) No Yes If yes, describe:
Description of Operations:
If New Operation/ Company- Describe the relative work experience of the principals:
Estimate Payroll: (Note, if “off premises” operations are applicable, give the amount and description, add page if necessary)
Estimated Annual Sales or Receipts:
If more than one operation/ product, give $ or % breakdown per capita:
Work Performed
The percentage of construction work which is:
Residential	Commercial	Industrial
Work Sublet? No Yes , amount $
Description:
Are subs insured? No Yes If yes, limit requested?	Certification of insurance for subs obtained? No Yes
Are there any off premises welding or cutting operations? No Yes, amount or %
Sales to U.S.A? No Yes, amount	Description:
Previous Policy History
Previous Insurer:	Policy #:	Deductible:
Claims Experience: Describe all liability losses, paid or reserved over the last 3 years:
Has any insurer cancelled, declined, or refused to renew or reissue insurance of the type applied for? No Yes
If yes, give reason:
Coverage
Bound Not Bound	Effective Date:	Limit Required?
Deductible?
Frills Required:

Producer:

Information Taken By:	Date: