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CGA Specialty Office Insurance Application.

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:

Applicant Information Section
First Name:
Last Name:
Business Name:
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip Code:
Phone Number:
Fax Number:
E-Mail Address:

Underwriting Questions
Property Address:
Property City:
Property State:
Property Zip Code:
Property County:
Please Describe the Nature of Your Business
Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
Current Insurance Company:
Business License Number:
License Type:
Years of Experience:
How Many Years Have You Operated This Business:
How Many Stories:
If Two Stories, Ground Floor Square Footage:  
Total Square Footage of Your Dwelling:  
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Protection Distance:
Is The Business In A Brush Area? yes  no  
Is This Business Open 24 Hours A Day? yes  no  
Any Deep Frying (Food)? yes  no  
Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? yes  no  
Is there Filing Of Propane Tanks? yes  no  
Is There Storage More Than 1500 Sq Ft? yes  no  
If An Office Risk, Is E&O With 1 Million Admitted Coverage Carried? yes no  
Are There Smoke Detectors At This Location? yes no  
Smoke Alarm: yes no
Fire Extinguisher: yes no  
Deadbolts On All Doors? yes no
Circuit Breakers: yes no
Electrical Updated:
Heating - Air Conditioning, Thermostatically Controlled?: yes no 
Heating - Air Conditioning, Central? yes no 
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers: 
Theft Alarm:
Fire Alarm:
Losses-Claims in the last 5 years:   
If yes, date, amount paid and description of each loss-claim

Coverage Information Section
Building Coverage:
Other Structures Coverage:
Business Contents Coverage:
Loss of Use Coverage:
Liability Limits Requested:
Policy Deductible:
Questions or Comments
to help the Producer:

 
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