Name* Last Legal Entity Name Business Established on Mailing Address City State / Province / Region Postal / Zip Code Phone* Email* Effective Date Years experience in same field Any Prior ClaimsYesNo Details of claim Details of all services Provided IndustryCatererFood TruckFlooring SuppliesDay Care / Day HomeDriving SchoolEventGarage(dealer, Repair shop etc.)Home Based BusinessLiquor StoreOffice(Lawyer,Insurance Broker, Realtors etc.)RealityRented DwellingRestaurantRetail storeSalon and Spa Licenses, educational qualification,relevant certification Licenses, educational qualification,relevant certification Subcontractors used ?YesNo Details of work sub contracted Revenue last year Revenue current year Commercial General Liability (in USD) min:$2000000 max:$5000000 Loss of Income coverage required ?YesNo Buildiing/Improvements & Betterments coverage (in USD) min:$5000 max:$200000 Equipment / Business Property limit (in USD) min:$10000 max:$500000 I understand that under insuring tools/ property to their replacement value can result in Co Insurance Penalty and I might not get full reimbursement for my loss in case a claim happens Yes Do you required any other coveragesYesNo If additional coverage required, then, Please explain type of coverage & limit I confirm all necessary licenses, permits, etc. have been obtained and business is in full compliance with government lawsTrueFalse Other documents Remark By Typing my name below,I confirm all the information provided above is true and that coverage required are strictly per my instructions(required) Date Signed
