Insurance CGL Application

INSURANCE CGL APPLICATION

Applicant / Insured Information

Applicant Name:

Individual    Partnership    Corporation    LLC    Nonprofit    Other:

Date of Birth (principal/owner, if individual):

Business Operations

Operations performed off-premises (work at customer locations): Yes   Operations outside the United States: Yes   If yes, list countries:

Policy Details — Coverage Requested

Requested Policy Period From: To:

Coverage Form: Occurrence    Claims-Made   Retroactive Date (if applicable):

General Liability    Products/Completed Operations    Personal & Advertising Injury    Fire Legal Liability    Medical Payments    Liquor Liability

Loss History / Prior Claims (Last 5 Years)

Have any claims, suits or incidents been reported in the prior five years? Yes    No

Exclusions, Representations & Acknowledgements

The applicant acknowledges that the standard policy excludes certain classes of loss unless specifically endorsed. Applicant must indicate acknowledgement of the following common exclusions by checking each box. Checking an exclusion indicates applicant has read and understands the exclusion may apply and that additional endorsements may be required for coverage.

Asbestos and related contamination exclusions
Pollution and contamination exclusion (except limited on-site cleanup if endorsed)
Professional or Errors & Omissions exclusion
War, nuclear and similar perils exclusion
Intentional acts and criminal acts exclusion
Workers' compensation / employer's liability exclusion (coverage not provided under CGL)
Sexual misconduct / abuse exclusion (may be subject to special underwriting review)

Fraud / Material Misrepresentation: The undersigned declares that, to the best of their knowledge, the statements made in this application are complete and true. Any material misrepresentation, omission of relevant fact, or failure to cooperate with insurer may invalidate coverage or be grounds for rescission, denial of coverage, or refusal to renew. Applicant consents to insurer obtaining loss history and underwriting information from prior carriers and other sources.

Applicant authorizes the release of claim loss runs, payroll records, and relevant contracts to the insurer for underwriting purposes. Applicant understands that acceptance of this application by the insurer does not bind coverage until a policy is issued and premium is paid as required by the insurer.

Certification: I certify that I am authorized to complete this application on behalf of the applicant and that the information provided herein is accurate and complete. I understand that false information may result in denial of coverage for claims and potential penalties under applicable law.

Applicant declares that any contracts, leases or hold-harmless agreements executed require additional insured status or primary/non-contributory wording to be provided to those parties; applicant must submit such agreements for review before additional insured endorsements are issued.

Beneficiary / Certificate Holder (if applicable)

Documentation Checklist

Please indicate attachments submitted with this application:

Prior policy declarations and endorsements
Loss runs (five years)
Sample contracts / leases (if additional insured requested)
Safety programs / training documentation
Financial statements or proof of receipts

Declarations & Signature

By signing below the applicant warrants that the information provided in this application is true, accurate and complete. The applicant understands that the insurer will rely on this information in determining eligibility, underwriting terms, and premium. The applicant agrees to promptly report any material changes in operations or exposures prior to policy inception or during the policy period.

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