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Witkin Insurance

Call Us: (323) 457-5294

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- Workers Comp

Commercial General Liability Policy
Application

Please complete the form so we can help you secure the coverage you need

Applicant Information

First name*

Last name*

Email*

Phone*

Business Legal Name*

This business uses a separate Doing Business As (DBA) or operating name

Business Address

Business Address

Country/Region*

Address*

City*

Zip / Postal code*

Business Details

What industry represents the majority of the business’ revenue?*

Number of Employees (including owner)*

When did you start your business?*

Estimated Revenue*

Estimated Payroll*

How is your business structured?*

Does your business own or operate out of more than one building?*

Yes

How many years of experience have you had in your trade/profession?*

What is your estimated subcontractor (IRS Form 1099 workers) cost over the next 12 months (if any)?*

*Please provide your best estimate. Your policy may be subject to an audit to verify this information.

Has your business, or any of its officers, owners, or partners:*

Been convicted of a felony in the past 5 years?

Declared bankruptcy in the past 3 years?

Had business-related lawsuits, mediations, or arbitrations filed against them in past 5 years?

Had a defect claim in the past 10 years?

Become aware of any accidents or circumstances that might give rise to a claim against this policy?

None of the Above

How many liability claims have you had in the past 3 years?*

Do you currently have a general liability policy in effect?*

Yes

Does your business use any vehicles that it does not own?*

Yes

Are you required to name a third party as an additional insured or loss payee on your policy? (i.e. bank, landlord, etc.)*

Yes

LIC# 4416083

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Call Us: (323) 457-5294

Commercial General Liability Policy Application

Commercial General Liability Policy
Application