Commercial General Liability Insurance Questionnaire Name * First Name Last Name Email * Phone (###) ### #### Company * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Description of business / services provided: Legal Entity Individual Partnership Corporation LLC Other Legal Entity Other Building Construction (Wood) Frame Joisted Masonry Non-combustible Masonry Non-combustible Fire resistive Square footage occupied by your business Number of years in business Number of years experience in this type of business: Employer ID # (FEIN): Total estimated annual sales/receipts/revenue: Total estimated annual payroll for direct employees: How much of that amount is Full Time employees? How much of that amount is Part Time employees? Are Subcontractors / Independent Contractors used? Yes No If yes, do you require a certificate of insurance as evidence of their own insurance? Yes No Total annual cost / payroll for subcontractors GENERAL LIABILITY COVERAGE Please provide copy of lease requirements from your property manager [if applicable] Per Occurence / Aggregates $1,000,000 / $2,000,000 $2,000,000 / $4,000,000 Additional Insured If your lease requires ADDITIONAL INSURED status for your Landlord and/or Property Manager please provide the name and address as it should appear on Certificate of Insurance UMBRELLA LIABILITY [OPTIONAL COVERAGE] (For an additional premium) This coverage would respond if the Liability limits on your scheduled underlying General Liability [Businessowners], Employers Liability [Workers Compensation] and/or Business Auto Liability policies were to be exhausted / depleted due to a covered catastrophic loss. Desired Limit $1,000,000 $2,000,000 Other If Other amount, enter below Are any autos titled in the name of, owned by or leased by your business? If yes – please contact us regarding Business Auto coverage options. Yes No Policy Effective Date Requested: MM DD YYYY Applicant Signature Owner, Officer or Partner Todays Date MM DD YYYY Thank you!
