| Applicant (First Named Insured)* |
|
| Effective date* |
|
| Expiration date* |
|
|
|
| New or renewal? |
|
| Proposed retroactive date |
|
| Expiring policy number |
|
|
| Limit each occurrence ($)* |
|
| Current retroactive date* |
|
|
| Retained limit ($) |
|
| First dollar offense? |
|
|
|
| Location Number |
|
| Name and location of primary and all subsidiary companies* |
|
| Annual payroll ($)* |
|
| Annual gross sales ($)* |
|
| Foreign gross sales ($)* |
|
| Number of employees* |
|
|
|
| Carrier/Policy number |
|
| Policy effective date |
|
| Policy expiration date |
|
| Limits: CSL/Bodily injury each occurrence amount ($) |
|
| Annual renewal premium ($) |
|
| Limits: Bodily injury each person ($) |
|
| Annual renewal premium ($) |
|
| Limits: Property damage each accident ($) |
|
| Annual renewal premium ($) |
|
| Rating mode |
|
|
| General type |
|
| Carrier/Policy number |
|
| Policy effective date |
|
| Policy expiration date |
|
| Limits: each occurence ($) |
|
| Limits: general aggregate ($) |
|
| Annual renewal premium: Premium/operations ($) |
|
| Limits: products and comprehensive operations aggregate($) |
|
| Limits: personal and advertising injury ($) |
|
| Annual renewal premium: products ($) |
|
| Limits: damage to rented premises($) |
|
| Limits: medical expense($) |
|
| Annual renewal premium: other ($) |
|
| Rating mode |
|
|
| Carrier/Policy number |
|
| Policy effective date |
|
| Policy expiration date |
|
| Limits: each accident ($) |
|
| Limits: disease, each employee ($) |
|
| Limits: disease policy limit ($) |
|
| Annual renewal premium ($) |
|
| Rating mode |
|
|
| Are defense costs within aggregate limits?* |
|
| Explain |
|
| Are defense costs a separate limit?* |
|
| Expain |
|
| Are defense costs unlimited?* |
|
| Explain |
|
| Indicate the edition date of the iso simplified form or similar filing for the underlying coverage |
|
| Has any product, work, accident, or location been excluded, uninsured, or self insured from any previous coverages?* |
|
| Explain |
|
| For claims made, indicate the retroactive date of current underlying policy |
|
| For claims made, indicate entry date into uninterrupted claims made coverage |
|
| For claims made, was tail coverage purchased for any previous primary or excess policy? |
|
| If YES, effective date |
|
|
| Any auto (symbol 1)? |
|
| CGL claims made |
|
| CGL occurrence |
|
| Coverage: aircraft liability |
|
| Exposure: aircraft liability |
|
| Explain |
|
| Coverage: aircraft passenger liability |
|
| Exposure: aircraft passenger liability |
|
| Explain |
|
| Coverage: additional interests |
|
| Exposure: additional interests |
|
| Explain |
|
| Coverage: care, custody, control |
|
| Exposure: care, custody, control |
|
| Explain |
|
| Coverage: employee benefit liability |
|
| Exposure: employee benefit liability |
|
| Explain |
|
| Coverage: foreign liability/travel |
|
| Exposure: foreign liability/travel |
|
| Explain |
|
| Coverage: garage keepers liability |
|
| Exposure: garage keepers liability |
|
| Explain |
|
| Coverage: incidental medical malpractice |
|
| Exposure: incidental medical malpractice |
|
| Explain |
|
| Coverage: liquor liability |
|
| Exposure: liquor liability |
|
| Explain |
|
| Coverage: pollution liability |
|
| Exposure: pollution liability |
|
| Explain |
|
| Coverage: professional liability (E&O) |
|
| Exposure: professional liability (E&O) |
|
| Explain |
|
| Coverage: vendors liability |
|
| Exposure: vendors liability |
|
| Explain |
|
| Coverage: watercraft liability |
|
| Exposure: watercraft liability |
|
| Explain |
|
| Underlying insurance coverage information (include all restrictions; e.g. laser endorsements, discrimination, subrogration waivers, or extensions of coverage) |
|
| Previous experience (give details of all liability claims exceeding $10,000 or occurrences that may give rise to claims, during the past 5 years, whether insured or not. Specify date, coverage, description, amount paid, amount outstanding.) |
|
|
| Location |
|
| Property type |
|
| Value |
|
| Applicant role (if OTHER, explain) |
|
| Explain |
|
| Square footage of building occupied |
|
| Occupancy/Description of personal property |
|
|
|
|
| Media used |
|
| Annual cost of media used ($) |
|
| Are services of an advertising agency used? |
|
| Explain |
|
| Explain |
|
|
| Does applicant own/lease/operate aircraft? |
|
| Explain |
|
|
| Are explosives, caustics, flammables, or other dangerous cargo hauled? |
|
| Explain |
|
| Are passengers carried for a fee? |
|
| Explain |
|
| Any units not insured by underlying policies? |
|
| Explain |
|
| Are any vehicles leased or rented to others? |
|
| Explain |
|
| Are hired and non/owned coverages provided? |
|
| Explain |
|
|
| Is bridge, dam, or marine work performed? |
|
| Explain |
|
| Describe typical jobs performed |
|
| Describe agreement |
|
| Does applicant own, rent, or otherwise use cranes? |
|
| Explain |
|
| Do subcontractors carry coverages or limits less than applicant? |
|
| Explain |
|
|
| Is applicant self insured in any state? |
|
| Explain |
|
| Subject to: (explain if OTHER) |
|
| Explain |
|
|
| Is a hospital or first aid facility maintained? |
|
| Explain |
|
| Are coverages provided for doctors/nurses? |
|
| Explain |
|
| Indicate number of doctors |
|
| Indicate number of nurses |
|
| Indicate number of beds |
|
|
| EPA number |
|
| Do current or past products, or their components, contain hazardous materials that may require special disposal methods? |
|
| Explain |
|
| Is the following coverage carried: GL with standard iso pollution exclusion? |
|
| Is the following coverage carried: GL with standard sudden and accidental only? |
|
| Is the following coverage carried: GL with pollution coverage endorsement? |
|
| Is the following coverage carried: Separate pollution coverage? |
|
|
| Are missiles, engines, guidance systems, frames, or any other product used/installed in aircraft? |
|
| Explain |
|
| Are foreign products distributed in U.S.? |
|
| Explain |
|
| Product liability loss in past 3 years? |
|
| Explain and specify |
|
| Gross sales from 3 years ago |
|
| Gross sales from 2 years ago |
|
| Gross sales from 1 years ago |
|
|
| Describe independent contractors |
|
|
| Does applicant own or lease watercraft? |
|
| Explain |
|
| Number watercraft owned |
|
| Length of watercraft |
|
| Horsepower of watercraft |
|
|
| Number of stories |
|
| Number of units |
|
| Number of swimming pools |
|
| Number of diving boards |
|
|
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
|
| Number of vehicles owned |
|
| Number of vehicles non-owned |
|
| Number of vehicles leased |
|
| Property hauled |
|
| Distance |
|
