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Home > General Liability Application

General Liability Application

General Liability Form

* indicates required fields

Named Insured:*

Email*

Phone Number*

Mailing Address:*

Street Address Address Line 2 City State ZIP Code

Physical Address:*

Street Address Address Line 2 City State ZIP Code

New Venture:

Business Information

Years in Business Under Current Name:

List all Previous Business Names:

Include any additional names by clicking the "+" icon to your right

Proposed Effective Date:*

MM slash DD slash YYYY

Business Name*

As Shown Exactly on Contractors License or License Application

States in Which You Are Licensed to do Business:

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Northern Mariana Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

U.S. Virgin Islands

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

(Select all that apply)

Are you a licensed:

(Select all that apply)

Contractor License Number(s):

Do you carry Work Comp for all employees?

Would you like a Workers Compensation quote?

Number of Active Owners in the Field:

Do you or your subs perform work on New Construction Condo/Townhome/Tracts?

Please select all that apply:

Condo

Townhome

Tract

Max units in entire development:

Max units you will perform on:

What percentage (%) of your work is:

Commercial:

Residential:

Industrial:

Other:

What percentage (%) of your work is:

New Construction:

Repair/Remodel:

What percentage (%) of your work is:

Interior:

Exterior:

Figures for the past 12 months:

Payroll (excl. owners):

Total Sub-Contract Costs:

Sub-Contract Cost (excl. materials):

Sales:

Estimate for the next 12 months:

Payroll (excl. owners):

Total Sub-Contract Costs:

Sub-Contract Cost (excl. materials):

Sales:

What percentage (%) of your work is done directly for:

Property Owner

GC

Narrative of business operations or experience:

Direct Payroll Work Performed – Excluding subcontractors, indicate the trade(s) and % of your operations:

Trade

Total Percentage (%)

Include additional trades by clicking the "+" icon to your right. Don't exceed 100%

Do any of your operations involve:

Asbestos Removal?

Pile Driving?

Blasting?

Shoring?

Underpinning?

Demolition (not incidental)

Railroad Work?

EIFS?

Foundation Work?

If Yes to any, explain:

Do you perform any exterior contracting operations exceeding 3 stories in height:

If yes, explain including max height:

Do you perform any Roofing projects?

If you perform any roofing operations, what percentage (%) of those are:

Hot Tar

Foam Application

Torch down

Residential over (3) stories

Recent Jobs – Provide details on the 3 most recent projects:

Subcontractors Exposure: Do you ever hire subcontractors?

If Yes, answer the following:

Do you always require subs to sign a hold-harmless in your favor?

Do you utilize a standard contract with all your subs?

Do you require all subs to carry equal or higher GL limits?

Do you require that you are named as an AI on their policy?

Do you maintain records of insurance for your subs for at least 5 years?

Do you require your subs to carry worker’s compensation insurance?

Are you involved in any work other than contracting?

If yes, explain

Have you, or will you, work as a construction manager/project manager for a fee?

If yes, explain

Premium History – Complete chart

Year

Carrier

Occurrence

Aggregate

Products

Expiring Premium

Include additional premiums by clicking the "+" icon to your right.

Are you being non-renewed by your current carrier?

If yes, why?

Have you ever had a lapse in insurance coverage?

If yes, why?

If yes, approximate dates of lapse:

Loss History – Include 5 years Currently Valued Loss Runs with your submission, if available.

Do you have a claim in the last 3 years?

If known losses exist, complete below:

Year

Open/Closed

Amount

Detailed Narrative

Include additional losses by clicking the "+" icon to your right.

Do you have a formal safety program in place?

Do any of your expected contracts require the following?

Blanket AI

Primary Wording

Waiver of Subrogation

Prod & Comp Ops AI

Stop Gap

(Select all that apply)

Target Premium:

(Needed to obtain best pricing)

Need by date:

MM slash DD slash YYYY

New Ventures Information

Owner’s resume:

(If new venture).

Signature

Signature of Applicant:

(Sign with your Full Name)

Today's Date

MM slash DD slash YYYY

Consent

I agree to the terms and conditions and understand that this is a quote solicitation.

Email

This field is for validation purposes and should be left unchanged.

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JN Insurance Services Inc.
26060 Acero Suite 888
Mission Viejo, California 92691

Phone: (949) 989-5054

Office Hours:

Mon-Thu: 8:00am-5:00pm
Fri: 8:00am-4:00pm
Sat-Sun: Closed

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JN Insurance Services Inc. provides general liability, surety bond, and excess liability insurance to all of California, including Mission Viejo. We also serve all of Texas.

See How Our Independent Insurance Agency Benefits You
See How Our Independent Insurance Agency Benefits You
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