Form Cg 75 - Artisan General Liability Application
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2BROKERING AGENT'S REGISTER NO. ______________________
AMERICAN RELIABLE INSURANCE COMPANY
VOYAGER INDEMNITY INSURANCE COMPANY
Artisan General Liability Application
Incomplete applications are subject to rejection of coverage and / or risk. Do no leave any questions blank or unanswered.
Name
Producer
DBA:
Effective Dates: 12:01 AM
Mailing Address
From:
To:
City
State
Type:
Individual
Corporation
Zip
County
Partnership
Joint Venture
Ph.#
Inspection Contact:
W eb Address:
Business address(s):
Description of business:
# Years Experience: _________
# Years in Business:
Classification Code(s)
What business is prior experience: ________________
Limits of Liability include - Occurrence, General Aggregate, Products/Completed Operations, Personal and Advertising Injury.
Certain classes include the Products / Completed Operations Hazard within the General Aggregate Limit.
Deductible: Property Damage - Automatic
Double Aggregate
Single Aggregate
$ 500.00
100/200
100/100
_______#Owners, Officers or Partners Payroll X *
=
300/600
300/300
* NC = $24,800
SC = $24,100
VA = $26,300
GA = $24,400
500/1,000
500/500
1,000/2,000
1,000/1,000
_______ #Full-time employees (not temp or leased) payroll =
_______ #Part-time, temp or leased employees payroll =
100,000 Fire Damage limit
5,000 Medical Payments
Total Risk Payroll =
% of your work is:
________%Residential
________%Commercial
________%Industrial
________%Manufacturing
W hat percentage of each day is owner working on jobsite? ___________%
Type of License:
Current License Number:
What operations do you perform?
Do you perform under written contract?
Yes
No
Do you subcontract any work?
Yes
No
If yes, % subcontracted: _______ %
Types of work subcontracted:
No (If No, submit risk)
Do you require certificates for General Liability equal to or greater than your own?
Yes
Do you require certificates for W orkers Compensation?
Yes
No
Types of jobs performed in the last 12 months:
Average Length of Jobs performed in the last 12 months: __________ circle one: days weeks months
Past And Anticipated Projects Detail:
Payroll
Subcontracted Costs
Gross Receipts
Prior 24 Months:
Next 12 Months:
Do you now or have you ever acted as a GENERAL CONTRACTOR?
Yes
No (If Yes, submit risk)
List other businesses owned now or in past 5 years: ______________________________
What counties do you work in: ________________________
If yes, list all losses below & Submit.
Any Prior Losses in the last 5 years?
Yes
No
No (If Yes, submit risk)
Do you have any knowledge of an occurrence that could result in a claim?
Yes
Prior Carrier / Loss History:
Date
Carrier
Premium
Losses
LOSS INFORMATION
Have you ever had prior insurance cancelled, declined or non-renewed?
Yes
No
If yes, explain: ________________________________________________________________________________________________________________
Have you or your company ever operated for any period without insurance?
Yes
No
If yes, explain: ________________________________________________________________________________________________________________
CG 75 01 01 07
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