Untitled Document

CGA JANITORIAL (Commercial/Residential) Insurance Application
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. 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:

Application Information Section

Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Applicant is:	Individual Corporation Partnership Joint Venture Other:

Limits of Liability

Limits of Liability Requested

General Aggregate $ Each Occurrence $

Products & Completed
Operations Aggregate $ Fire Damage (any one fire) $

Personal & Advertising Injury $ Deductible $

A. How long has applicant been in business?
Total number of employees:

B. Does applicant have Workers' Compensation coverage in force? Yes No

C. Does applicant lease employees? Yes No

D. Describe operations of applicant:

Office Buildings % Apartment Buildings %

Industrial Buildings % Hotels %

Shopping mall/center % Theatres/movie houses %

Supermarkets/dept. stores % Hospitals %

Retail stores % Sports complex %

Terminals % Convention halls %

       Airport
       Railroad
       Bus
       Shipyard Private residences %

Window cleaning    Max. # of stories    Scaffolds/rigging    Rented Owned
        Contract with:

E. Annual PAYROLL information:

Janitorial $ Owner $

Window Cleaning $ Employees $

Carpet Cleaning $

Floor Waxing $

Pool Service $

Other $

F. Annual SALES information:

Janitorial $ Owner $

Window Cleaning $ Employees $

Carpet Cleaning $

Floor Waxing $

Pool Service $

Other $

G. Does risk store L.P.G., flammable liquids, ammunition or explosives on the premises? Yes No
If so, type and quantity stored:

H. Does risk lend, lease, or rent any equipment to others? Yes No
If so, state the type of equipment involved and the gross receipts derived therefrom:

I. Does applicant subcontract work? Yes No
If so, state type:

Are certificates of insurance required from all subcontractors? Yes No

J. During the past three years has any company ever cancelled, declined or refused to renew similar insurance for the applicant? Yes No
If yes, explain:

Previous Insurer: Indicate premium and losses for the past three years. Describe all losses.

Year Company Policy # Premium Losses
Paid Losses
Reserved Description

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.