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CGA Personal Liability Insurance Quote Form

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

General Information
Name of Business:
Inspection Contact Name:
Mailing Address:
City: 

  State:   Zip:
Location Address:
City: 

  State:   Zip:
Business Phone:   Fax:
Contact Email Address:
Business Status:     Years in Business:

Current Insurance Information
Company Name
(not agency):		     Premium: $
Effective Date:   Expiration Date:
Please List Any Other Previous Carriers Over the Past 3 Years Below:
Carrier Name:     Premium: $
Carrier Name:     Premium: $

Project/Work Information
Please write a Description of Operations below:
What percentage of your work is: 
(each line must total 100%) 		 Commercial  %  Industrial  %  
Residential  %

New Construction  %
Remodel/Additions  %
What percentage of your work is as a:  General Contractor:  %
Subcontractor:  %
What percentage of your work is: Subcontracted Out:  %
Sub Costs: $
Do you collect certificates of insurance at a $1,000,000 limit?:   Yes     No

Receipts / Payroll / Dollar Value Info
Gross receipts for the past 3 years: 
and the next 12 months: 		 (3rd yr prior) $    
(2nd yr prior) $
(Last 12 mths) $
(Next 12 mths) $
Number of owners/officers/partners active at the job site or supervising:     
Payroll of employees excluding owners, officers, partners & clerical:    $
Dollar value of average job completed
incl. all materials, labor & equipment: 		   $
Describe any project(s) underway or planned for the next year, including values below:

Miscellaneous and Legal Info
Have you ever performed ground up construction involving condominiums, townhouses, apartments, or single family tract developments of two (2) or more?:     Yes    No
Have you ever been named in litigation regarding faulty construction?:     Yes    No
Are there any claims or legal actions pending?:     Yes    No
Do any of the entities named in the application have knowledge of any pre-existing act, omission, event, condition or damages to any person or property that may potentially give rise to any future claim or legal action against any such entity?:     Yes    No

 

Claims History
Enter all claims or occurrences that may give rise to claims for the prior 3 years.
This information is kept strictly confidential

Claim #1   Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

Claim #2   Claim Status: Closed   Open
Date of Occurrence:   Date of Claim:
Type/Description of Occurence or Claim:
Amount paid on your behalf: $   Amount reserved on behalf: $

 

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.

 
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