General Liability Policy Renewal Questionnaire "*" indicates required fields Policy Number* Policy Type* Policy Expiration Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Carrier Policy Holder Name* First Last Email* PhonePhone Ext.Business Name* Policy City* Policy State*Please select the policy stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPlease provide your projected figures for the upcoming policy term (Eff - Ren)Total Projected Gross Receipts*Total Projected Field* Payroll** Do not include owners/clericalNumber of Employees*** Do not include owners/clericalTotal Projected Subcontracting Costs*Type of Work Subcontracted Out* Description of Operations*Please provide the work type percentage breakdown for the upcoming termTotal must equal 100%% New* % Remodel* % Repair* Please provide the structure type work percentage breakdown for the upcoming termTotal must equal 100%% Residential* % Commercial* % Industrial* Please provide the interior / exterior work percentage breakdown for the upcoming termTotal must equal 100%% Inside Building* % Outside Building* Please provide the confirmation of work for the upcoming termAny Roofing Operations?* Yes No Any School/Rec Work Performed?* Yes No Any Church Work Performed?* Yes No Any Hospital Work Performed?* Yes No Any Wrap (OCIP) Work Performed?* Yes No Please Provide the % of Wrap (OCIP) Work Performed?* Any Work For HOAs On/In Condos, Townhomes or Tract Housing Within the Past Year or Planned In the Coming Year?* Yes No If Yes, Please Explain* Please indicate the endorsements required by contractAdditional Insured Required* Yes No Waivers of Subrogation & Primary Wording* Yes No AI For Completed Ops* Yes No Per Project Aggregate* Yes No SignatureFirst & Last Name Date* Month Day Year EmailThis field is for validation purposes and should be left unchanged.
