CPL Quote - Graham-Rogers

Agency Name *

Agency Code *

Agent First Name *

Agent Last Name *

Agent Email *

Agent Phone Number *

Entity Type *

Insured First Name & Last Name *

Applicant Phone *

Applicant's Email Address *

Mailing Address *

Country

City

State

Zip code

Requested Effective Date *

Any applicant considered a high profile risk such as politicians, entertainers and professional athletes? (Referral) *

Yes

No

Explain: *

Has the applicant had any claims in the last 5 year? *

Yes

No

CPL or Excess CPL? *

Comprehensive Personal Liability

Excess Comprehensive Personal Liability

Primary Limit of Insurance *

Excess Limit Requested *

Requested Amount *

Location 1 *

Country

City

State

Zip code

Location 1 Occupancy *

Location 1 reason for vacancy *

Add location 2? *

Yes

No

Location 2 *

Country

City

State

Zip code

Location 2 Occupancy *

Location 2 reason for vacancy *

Add location 3? *

Yes

No

Location 3 *

Country

City

State

Zip code

Location 3 Occupancy *

Location 3 reason for vacancy *

Add location 4? *

Yes

No

Location 4 *

Country

City

State

Zip code

Location 4 Occupancy *

Location 4 reason for vacancy *

Add location 5? *

Yes

No

Location 5 *

Country

City

State

Zip code

Location 5 Occupancy *

Location 5 reason for vacancy *

Type of claim *

Claim Date *

Amount paid out *

Explain the claim and if repairs have been made *

Add another claim? *

Yes

No

Type of claim? *

Claim Date? *

Amount paid out? *

Explain the claim and if repairs have been made? *

Add another claim: *

Yes

No

Type of claim: *

Claim Date: *

Amount paid out: *

Explain the claim and if repairs have been made: *

Do you employ any residence employees? *

Yes

No

Provide what they are employed to do: *

Are any applicant currently insured with Hudson, RLI, USLI? *

Yes

No

Provide carrier and policy number: *

Any locations owned by an LLC or Trust? *

Yes

No

Explain: *

Is the location used as student housing, a rooming house, assisted living facility, group home, or model home? *

Yes

No

Explain: *

Do any hazardous conditions, such as cracks, holes, uneven sidewalks, an accumulation of debris, or broken or defective steps, handrails or porches, exist? *

Yes

No

Explain: *

Is the location over 6,000 square feet? *

Yes

No

What is the square footage? *

Are any business activities (including daycare) conducted from your residence or premises (excluded in policy jacket) *

Yes

No

Explain: *

Any animals in the household? *

Yes

No

Please list below including breed, bite history, fighting or security training, if applicable. *

Any land used for hunting or farming? *

Yes

No

Explain: *

Any swimming pools? *

Yes

No

Please specify fenced or unfenced, diving boards or slides *

Any other underwriting information of which Company should be aware? *

Yes

No

Advise: *

Please provide underlying declarations page: *

Please provide any supporting documentation you may have:

Any Additional Questions or Comments?

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Comprehensive Personal Liability Quote

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