Commercial General Liability Application

Applicant's Name

Email Address

Form of Business

Individual Corporation Partnership LLC Other

Mailing Address

City

State

Zip Code

Is your physical address different than above?

Yes No

Phone Number

Fax Number

Website Address

Inspection Contact

Coverage Desired

Liability Property Liquor Package

Policy Term

3 Months 6 Months 9 Months Annual

Has coverage been cancelled or non-renewed in the last 3 years (not applicable in the state of MO)?

Yes No

What year did the business start?

Annual Revenues Generated

Do you hire subcontractors?

Yes No

In how many events per year does your company participate?

Do you sell any of the following products: Collectables and memorabilia (old), Drugs, Prepackaged & Non-prescription, Heading Aids, Hobby or Craft, Optical Goods prescription, Toys, any used or refurbished products, or any products manufactured by applicant or sold under applicants name or label (not including prepared foods or jewelry)? ***Risk is still eligible. However, Products/Completed Operations must be excluded.***

Yes No

Do you operate inside an amphitheater, arena, ballpark, concert hall, stadium, or theatre with seating for more than 2,500?

Yes No

Are you responsible for no more than 40 stands / kiosks?

Yes No

Does applicant generate more than 50% of sales from tobacco, tobacco products, hookah, electronic cigarettes or other tobacco related products?

Yes No

Does the insured's operations involve customers entering on or into premises owned or leased by the applicant to shop? (If so, we must classify as a retail store or a restaurant)

Yes No

Is the applicant, have they been, or will they ever act as a franchisor (grantor of a franchise)?

Yes No

Is there or will there be any exposure to the following operations or services: Acupressure or Massage Services, Athletic Clubs or Activities, Bathroom Attendants, Coat Check, Contractors, Farms, Games of Chance, Ice Cream Trucks (Mobile), Mechanical Rides, Rock Climbing Walls, Tattoo or Body Piercing, Transportation Services, Trucks (Mobile vending trucks)?

Yes No

Is there any past, pending or planned foreclosure and/or bankruptcy or judgment for unpaid taxes against the named insured or any officer, partner, member or owner of the applicant individually within the past five (5) years?

Yes No

Is there or will be any sale of the any of the following products: Ammunition, Firearms or Weapons, Cars or Vehicles, Fire or security alarm or device, Fireworks, Flying or Aerial Objects, Medical Supplies, Massage products or any goods rented to others?

Yes No

Does the applicant engage in any operations or have any classifications on their premise(s) other than those listed?

Yes No

Each Occurrence	$1,000,000
Personal Injury and Advertising Injury	$1,000,000
Medical Expense (Any One Person)	$5,000
Damage to Premises Rented to You	$100,000
Products/Completed Ops Aggregate	Included
General Aggregate	$2,000,000
General Liability Deductible	$0
Additional Insured	Included
Business Personal Property	Available

Commercial General Liability Application

Eligibility

Limits of Insurance

COMMERCIAL GENERAL LIABILITY

Applicant's Warranty Statement