Section A: Applicant Information
Section B: Prior/Current Insurance Information
Section C: Insurance Limits (General Liability and Inland Marine)
Section D: Underwriting Information
Number of Employees (Excluding Owner)
Number of Certifications (Both Owner and Employees)
Estimated Payroll for the next 12 Months (Excluding Owner)
Breakdown Type of Work Done by Percentage:
Breakdown of Product Sales by Product Type:
Breakdown of Work Done by Percentage
Section E: Subcontracted Work
Section F: Retail Operations
Section G: Property Insurance
Section H: Residential/Commercial Operations
Section I: Claims History for the Last 5 Years
I/We hereby declare that the above statements and responses are accurate and true and that I/we have not omitted, misrepresented, or misstated any facts. I/We acknowledge that the statements and responses contained in this application shall become a part of the insurance policy issued by the Company and that any misrepresentation or omission may void such policy.
I/We understand and agree that the completion of this application does not bind the Company to issue, nor me to purchase a contract of insurance. However, if I/we are issued insurance by the Company and I/we purchase such contract of insurance, I understand and agree that the representations and answers contained herein this application shall be considered a part of such contract of insurance and shall be as fully a part of such contract as is fully set forth herein. Furthermore, I/we understand and agree that any misrepresentation or omission in this application may void the contract and give the Company a right to rescind the contract, in addition to any other right or remedy the Company may have.
I/We understand that failure to correct a misrepresentation on this or any other application, or the failure to disclose a material fact that I/we become aware of subsequent to the completion of this application but prior to the effective date of the policy to which it applies, may void the policy.
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