General Liability Questionnaire

Company Name (required)
License Number (required)
Phone (required)

Email (required)

Please give a detailed description of the work done by you and your employees

Rating Factors
(Please give a conservative estimate for the next 12 months)

Gross Receipts $
Employee Payroll $
Active Owners

Project Location Type
(% of each)

Residential %
Commercial %
Industrial %

Type of work performed
(% of each / new construction is prior to certificate of occupancy)
Service Repair Work %
Remodeling Work %
New Residential %
New Commercial %

Please list which trades you hire subcontractors for: -- Subcontracting Cost $

Any work performed for new groundā€up construction of tract homes, condos, or apartments yes no
Any work performed more than 15 feet off the ground yes no
Any work performed more than 3 feet below grade yes no
Has there been any prior claims or losses yes no
Do you currently have general liability insurance yes no
If Yes: Name of carrier -- Expiration Date

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