Form Cg 75 - Artisan General Liability Application Page 2
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1
2Answer the following questions. Do you or have you ever performed any of the following work:
Exposure to Radioactive
Excavation Tunneling
Yes
No Alarm Systems
Yes
No
or Nuclear Material
Yes
No
Blasting, demolition or any
explosive materials used
Yes
No Act as a General Contractor
Yes
No
Any Herbicides or Pesticides W ork
Yes
No
Have you ever been named
Tree or Limb Removal
Yes
No Any oil, gas or related work
Yes
No
in a construction defect claim
Yes
No
Any aircraft, railroad,
Does applicant draw plans,
W aste Removal
Yes
No
watercraft or auto work
Yes
No
designs or specifications
Yes
No
Any bridges, dams or
Any Cell Phone, W ater, Gas,
Asbestos Abatement
Yes
No
sewer construction work
Yes
No
Oil Tank, or Tower W ork
Yes
No
W axing Floors in Commercial
Rent, Lease or Repair Equipment
Yes
No Exterior work over 2 stories
Yes
No
buildings or stores
Yes
No
Chemical Spraying / Fumigating
Yes
No Any work with LPG
Yes
No
Underpinning / Foundation Repair
Yes
No
Digging more than
Any out-of-state Operations
Yes
No Fire Extinguisher Systems
Yes
No
Yes
No
3 feet underground
Ops. Involving discharge of
Coal, W ood, W aste or
fumes acids or waste
Yes
No Elevators, Escalators, Boilers
Yes
No
Oil Burning Stoves
Yes
No
W ork involving medical and/or
Any work with cranes of any
industrial equipment
Yes
No Fiber Optic Cable W ork
Yes
No
height, owned or leased
Yes
No
Operated as an inspection
or appraisal company
Yes
No Mold Fungus remediation work
Yes
No
Any Roofing or Root Related W ork
Yes
No
Real Estate Sales
Yes
No Engineering W ork
Yes
No
Any welding work
Yes
No
Any new building construction operations performed on single-family units including residential condominiums, multi-unit homes, tract housing, subdivisions, townhouses,
No (If yes, submit risk)
apartment buildings within subdivisions, single home valued over $750,000 or projects where there are five (5) or more total units?
Yes
If Yes; maximum of homes per project: ____________ (If yes, submit risk)
Any ground up construction custom home work or spec homes?
Yes
No
Please complete the separate Terrorism selection/rejection form as part of the application process
See form A8032G
Explain ALL "Yes" answers:
Name and Address of Additional Insureds
1.
2.
3.
SUBMIT completed and signed application for approval
This application does not bind the applicant nor the company to complete the insurance, but it is agreed that the
information contained herein ARE MATERIAL REPRESENTATIONS BY THE APPLICANT, and shall be the basis of the
contract should a policy be issued.
FRAUD WARNING
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
It is understood that the Brokering Agent is submitting this application to the insurer on my behalf and is acting as my
agent and is not an agent of the insurer. Therefore, the insurer and or its appointed representative is not bound by any
representation or warranty made by the Brokering Agent unless acknowledge by the insurer or its representative.
I understand this application is not a binder unless indicated as such on this form by the broker agent.
____________________________________________
____________________
Applicant Signature
Date
____________________________________________
____________________
____________________________
Licensed Agent / Producer Signature
Date
License #
CG 75 01 01 07
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