126 Commercial General Liability Section

Effective date*
Expiration date*
Applicant (First Name Insured)
Coverages:
Deductibles
Property damage deductible?
Deductible amount ($)
Bodily injury deductible?
Deductible amount ($)
Limits:
General aggregate ($)*
Products and completed operations aggregate ($)*
Personal and advertising injury ($)*
Each occurrence*
Damage to rented premises (each occurrence) ($)*
Medical expense (any one person) ($)*
Employee benefits ($)*
Schedule of Hazards:
Location 1
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 2
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 3
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 4
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 5
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 6
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 7
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 8
Location number
Classification
Class code
Premium basis
Exposure
Territory
Location 9
Location number
Classification
Class code
Premium basis
Exposure
Territory
Claims Made:
(Explain all yes responses)
Proposed retroactive date
Entry date into uninterrupted claims made coverage
Has any product, work, accident, or location been excluded, uninsured or self-insured from any previous coverage?
Explain
Was tail coverage purchased under any previous policy?
Explain
Employee Benefits Liability:
If coverage requested
Deductible per claim ($)
Number of employees
Number of employees covered by employee benefits plans
Retroactive date
Contractors:
Does applicant draw plans, designs, or specifications for others?
Explain
Do any operations include blasting or utilize or store explosive material?
Explain
Do any operations include excavation, tunneling, underground work or earth moving?
Explain
Do your subcontractors carry coverages or limits less than yours?
Explain
Are subcontractors allowed to work without providing you with a certificate of insurance?
Explain
Does applicant lease equipment to others with or without operators?
Explain
Money paid to sub-contractors
Percent of work sub-contracted
Number of full-time staff
Number of part-time staff
Products/Completed Operations:
Product 1
Product
Annual gross sales
Number of units
Time in market
Expected life
Intended use
Principle components
Product 2
Product
Annual gross sales
Number of units
Time in market
Expected life
Intended use
Principle components
Product 3
Product
Annual gross sales
Number of units
Time in market
Expected life
Intended use
Principle components
Explain All YES Responses
Does applicant install, service, or demonstrate products?*
Explain
Are foreign products sold, distributed, or used as components?*
Explain
Has research and development been conducted or new products planned?*
Explain
Guarantees, warranties, or hold harmless agreements?*
Explain
Are products related to aircraft/space industry?*
Explain
Products, recalled, discontinued, or changed?*
Explain
Are products of others sold or re-packaged under applicant label?*
Explain
Are products under label of others?*
Explain
Explain
Does any named insured sell to other named insureds?*
Explain
Additional Interest/Certificate Recipient:
Interest
Rank
Name of additional recipient
Address
City
State
Zip
Reference number
Certificate required?
Explain All YES Responses
Location
Vehicle
Building
Boat
Scheduled item number
Item description
General Information:
Explain All YES Responses
Any medical facilities provided or medical professionals employed or contracted?*
Explain
Any exposure to radioactive/nuclear materials?*
Explain
Do/Have past, present, or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous materials? (e.g. landfills, wastes, fuel tanks, etc)*
Explain
Any operation sold, acquired, or discontinued in last 5 years?*
Explain
Machinery or equipment loaned or rented to others?*
Explain
Any watercraft, docks, floats, owned/rented?*
Explain
Any parking facilities owned/rented?*
Explain
Is a fee charged for parking?*
Explain
Are recreation facilities provided?*
Explain
Is there a swimming pool on the premises?*
Explain
Are sporting or social events sponsored?*
Explain
Any structural alterations contemplated?*
Explain
Any demolition exposure contemplated?*
Explain
Has applicant been active in or is currently active in joint ventures?*
Explain
Do you lease employees to or from other employers?*
Explain
Is there a labor interchange with any other business or subsidiaries?*
Explain
Are day care facilities operated or controlled?*
Explain
Have any crimes occured or been attempted on your premises within the last three years?*
Explain
Is there a formal, written safety and security policy in effect?*
Explain
Explain