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Owens Insurance Agency- General Liability Application
Agent Name, address and email address
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Applicant's Name
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Insureds Phone number
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IF DBA list below
Type of Entity
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Mailing Address
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Limit of Liability Requested
Limit of coverage
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Month and Year business started
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Describe all business operations conducted by applicant
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Please list all location address
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LIMITS OF LIABILITY REQUESTED
General Aggregate
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Products & Completed Operations Aggregate
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Personal & Advertising Injury
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Each Occurrence
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Fire Damage
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Medical Expense
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Other Coverages, Restrictions, and/or Endorsements
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Deductible
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Total number of employees
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Annual Gross Sales (Gross sales is all receiptes before any deductions or payroll)
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Annual Payroll
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Expiration date or when did it expire
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Current Carrier and Renewal Premium
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5 year loss history
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Loss runs or current renewal offer
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