General Liability Application

Company Name:

 

Insurance Program

Renewal Date:

Contact:

Street Address:

City:

State:

Zip Code:

Email Address:

Phone:

Fax:

 

Gross Field Payroll Information:

 

Expected Gross Payroll: 

(do not include clerical or executive officers)

$
Number of Executive Officers in the Field: #

 

 

Please estimate the amount of payroll for the given Class Code:

 

Code: 97223

Machinery & Equipment Service, Installation or Repair

(Ex: Installations, Removals of lifts and automotive equipment

Payroll

$

# of Employees 

#

Code: 94007

Excavation

(Actual Time on Backhoe)

Payroll 

$

Code: 15062

Machinery & Equipment Dealers

(This is based on retail sales to third parties ONLY; Sales involving your own jobs/work are NOT INCLUDED)

Retail Sales

$

Code: 91581

Independent Contractors

(This is based on total cost of jobs)

Total Cost of Subcontractors 

$

 

Gross Sales Information:

 
2007 to 2008 Expected Gross Sales: 

$

2006 to 2007

 Gross Sales: $
2005 to 2006 Gross Sales: $

 

 

Please estimate the percentage of Gross Sales per the following class codes for the upcoming policy year:

 

Installation/Removal of Lifts, Automotive Equipment

%

Automotive Equipment Sales to Third Parties

%

 

%

 

%

 

%

 

%

 

Current Information:

 

General Liability Insurance Carrier
Pollution Coverage Insurance Carrier
If Claims Made, Retro Date ,

 

 

Please indicate which coverages you would also like quoted:

 

Commercial Auto
Equipment Floater
Commercial Property
Commercial Umbrella
Workers' Compensation

 

 

Please describe ALL General Liability Claims in the last 3 years:

 

 


 

If the form does not work properly, please print this form and fax it to 817.640.0131

...Or if you have already completed an application for another agent please fax that to us as it may have same information we require.
 

                   ©2007 Monroe & Monroe Insurance.  All Rights Reserved.                          Contact Us  |  Privacy Statement  |  Site Map