Applicants interest in premises: Owner: Yes No Lessee: No Yes Tenant: No Yes

Other (describe)

Is applicant: Sole owner /operator?: Yes No Partnership: No Yes Corporation: No Yes

Applicants years of experience in business: Years in current business:

Describe All Applicant's Operations:

Does Applicant operate or is Applicant part Owner in another Business?: No Yes

If so Describe:

Does Applicant Hire Sub-Contractors?: No Yes

If so Describe operations and cost of Hire for each:

Does Applicant secure certificates of Workers Compensation and Liability from all Sub-Contractors?: Yes No

If no will Applicant do so in the future?: Yes No Limits Required:

Does Applicant Issue Hold Harmless Agreements, Purchase Order Agreements or Assumption of Liability?: Yes No  

If Yes Please Forward Documents Via Fax to: 215-755-9908 Please make your Name or Company Name Clear.

Please Describe your Business and Type of Clients:

Name of Previous Insurer:

Limits: Premium:

Has Previous Insurer (1)Refused to Renew (2)Cancelled Coverage: Yes No

If Yes Why:

Loss Experience Past 5 Years:

Number Of Corp. Officers / Partners: Number of Other Employees: F/TP/T

Does Applicant carry Workers Compensation Insurance? Yes No

If Yes Why:

Applicants Gross Reciepts:

Policy Period: From: To:

Limits Of Liability:

Schedule

Deductible:

Additional Remarks:

Filing this form will not bind Applicant of the company to complete the insurance.