CGA Contractor Insurance Application
Submitting Information
Business Name:
Contact Name:
Street Address:
City:
State:
ZIP:
County:
Email:
Business Phone:
Fax:
Corporation Name:
Attention:
Title:
Administration
C.E.O
C.F.O
C.O.O
President
Executive Vice President
Controller
Vice President
Vice President of Operations
Vice President of Human Resources
Human Resources
Street Address:
City:
State:
ZIP:
Type of Corporation:
Individual
Joint Venture
Partnership
Limited Liability Corporation
Sub Chapter "S" Corporation
Corporation
Country:
Email:
Business Phone:
Fax:
Nature of Business Section
Type of Business:
Carpenter
Demolition
Drywall Installer
Electrical
Framer
General Contractor
Handiman
Heating and Air Conditioning
Home Builder
Landscaper
Masonry
Painting
Plumbing
Roofer
Window Installer
Years in Business:
Please describe your Business/Operation:
Premises Information Section:
Location Number:
1
2
3
4
5
Location Address:
City:
State:
Zip:
Property Coverage Section
Filler Box
Limits
Co Insurance
Valuation
Deductible
Building Limits:
60%
80%
90%
100%
No Copay
Replacement
Actual (ACV)
Agreed Amount
$250
$500
$1,000
$1,500
$2,500
$5,000
$10,000
Personal Property:
60%
80%
90%
100%
No Copay
Replacement
Actual (ACV)
Agreed Amount
$250
$500
$1,000
$1,500
$2,500
$5,000
$10,000
Loss of Rents:
50%
60%
70%
80%
90%
1/3 MO
2/3 MO
Select
Extra Expense
Boiler
Select
Extra Expense
Boiler
80%
90%
Agreed Amt
Replacement
Actual (ACV)
Agreed Amount
$250
$500
$1,000
$1,500
$2,500
$5,000
$10,000
Construction Type:
Frame
Joisted Masonry
Fire Resistive
Mod. Fire Resistive
Non-Combustible
Superior Construction
# of Stories:
1
2
3
4
5
6
7
>7
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:
100,000
300,000
500,000
1,000,000
2,000,000
(By Choosing the Split Limit, the system will automatically generate)
Each Occurrence Limit:
50,000
100,000
300,000
500,000
1,000,000
2,000,000
Liability Rating Section
Premium Basis:
Total Gross Annual Payroll:
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:
Describe Loss(es)
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