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CGA Contractor Insurance Application

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
Filler Box 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
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:

 
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