Insured Contact Information

Name

First Last

Email

Phone

Insured Business Information

Legal Name

First Last

DBA

Business Address

Mailing Address

Additional Locations

Coverages and Limits

Policy Term

General Aggregate

Each Occurrence

Employers Liability

Coverage History

Has the Applicant ever hired employees?

Yes

No

How many years of prior coverage does the Applicant have?

Why has coverage not been placed?

Additional Coverage History

Effective Dates

Carrier

Premium

Claim Count

Loss Information

How many claims has the insured had in the past 4 years?

Additional Business Information

FEIN

Experience Mod

Business Entity

Years of Industry Experience

Year Business was Established

Website

Blanket Waiver of Subrogation

Contractor License #

California Motor Carrier Permit Number

Public Utilities Commission Number

Owners and Operations

Class Code

Sub-Class Code

Description

Annual Payroll

No. of PT Employees

No. of FT Employees

Owners

Name

Title/Relationship

Owner %

Excluded/Included

Description of Operations

CNA Statements

General UW Statements CNA Connect, Workers' Compensation, Commercial Auto, Umbrella

Bankruptcies, receiverships, tax or credit liens within the past five years. If any owned, leased or rented locations in Indiana have underground or above ground storage tanks (past or present). If any prior policies excluded a specific location, service, product or other business exposure. If any services or products have ever been self-insured. If any owned, leased, or rented locations in Indiana are on sites previously occupied as a gasoline service station.

Class code statements

Confirm no structural demolition performed. Confirm no work is performed more than 20 feet / 2 stories above ground level. Confirm no work is performed more than 6 feet below grade. Confirm of formal fall protection plan in place when working above ground level. Confirm proper guards are installed on all tools and/or machinery. Confirm the insured maintains certificates for all subcontractors used. Confirm total subcontractor costs do not exceed 75% of total operations. Confirm use of stilts does not exceed 36 inches.

Construction class code statements

Confirm Personal Protective Equipment (PPE) is made available to employees and enforced. Confirm the insured holds an active license with the Contractors State License Board. Confirm the insured maintains certificates for all subcontractors used. Confirm total subcontractor costs do not exceed 75% of total operations.