Untitled Document

CGA Apartment Insurance Application Form
For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes only!

Submitting Information

Business Name:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	Fax:

Corporation Name:
Attention:
Title:
Street Address:
City:	State: ZIP:
Type of Corporation:
Country:
Email:
Business Phone:	Fax:

Nature of Business Section

Type of Business:
Years in Business:
Please describe your Business/Operation:

Premises Information Section:

Location Number:

Location Address:

City: State: Zip:

Property Coverage Section

	Limits	Co Insurance	Valuation	Deductible
Building Limits:
Personal Property:
Loss of Rents:

Construction Type:		# of Stories:		Year Built:

Is the Building Sprinklered? Yes No

Any Building Improvements? Yes No

If yes, please describe:

Liability Section
(Choose the limit options compatible with the program you are requesting)

General Aggregate Limit: (By Choosing the Split Limit, the system will automatically generate)

Each Occurrence Limit:

Liability Rating Section

Classification:
Premium Basis:
No. of Units:

Please note that in the amount section you will enter in the premium basis amount which could be one of the following:(P) Payroll , (S) Gross Sales, (A) Area, (U) Unit, (M) Admissions

Prior Policy/Loss History

Previous Carrier: Policy Number:
Any Losses? Yes No
If yes, please describe: