Prospect is best described as:

Contractor
Any Other Type of Business

Describe All Operations

Describe Any Relationship
Building Coverage   Yes No
 

Applicant's Information

In Business for  Years  or New # Yrs Experience Coverage Effective Date   

Agent's Information

Lines of business for submission

General Liability Special Events
Contents, Building, Tools Employment Practices Liability
Workers Compensation Directors and Officers Liability
Commercial Automobile Professional Liability
Umbrella N.Y. State DBL
Other

Property Info

Construction      Frame      Joisted Masonry      Non-Combustible      Masonry/Non Combustible      Fire Resistive

Other building tenants
Yes No
How many tenants
SQ Ft and Description of each

Policy History

Have any of your insurance Policies been cancelled or non-renewed in the past three years     Yes No
Explain

 
Prior
Coverage
 
Most Recent
Ins Carrier
Do we have a
Copy of the
Current Policy
 
Coverage
Lapses
 
Number of
Policy Years
 
Expiring
Premium
General Liability
Yes No
Yes No
Yes No
Property
Yes No
Yes No
Yes No
Workers Compensation
Yes No
Yes No
Yes No
Commercial Automobile
Yes No
Yes No
Yes No
Umbrella
Yes No
Yes No
Yes No
Employment Practices
Yes No
Yes No
Yes No
Directors and Officers
Yes No
Yes No
Yes No
Professional Liability
Yes No
Yes No
Yes No
N.Y. State DBL
Yes No

Any claims in the last four years
Yes No