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Great Northern Insurance Agency
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General Liability Quote

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For Help Call 1-(248)-856-9000

GENERAL INFORMATION

Fields marked (*) are mandatory

NAME OF BUSINESS

INSPECTION CONTACT NAME

MAILING ADDRESS

CITY

STATE

ZIP

LOCATION ADDRESS

BUSINESS PHONE

CONTACT EMAIL ADDRESS

FAX

BUSINESS STATUS

YEARS IN BUSINESS

CURRENT INSURANCE INFORMATION

Fields marked (*) are mandatory

COMPANY NAME (NOT YOUR AGENCY)

PREMIUM

EFFECTIVE DATE

EXPIRATION DATE

Please List Any Other Previous Carriers Over the Past 3 Years Below:

CARRIER NAME

PREMIUM

CARRIER NAME

PREMIUM

PROJECT/WORK INFORMATION

PEASE WRITE A DESCRIPTION OF OPERATIONS

What percentage of your work is (each line must total 100%)

COMMERCIAL (%)

INDUSTRIAL (%)

RESIDENTIAL (%)

NEW CONSTRUCTION (%)

REMODEL/ADDITIONS (%)

What percentage of your work is as a

GENERAL CONTRACTOR (%)

SUBCONTRACTOR (%)

What percentage of your work is

SUB CONTRACTED OUT (%)

SUB COSTS ($)

DO YOU COLLECT CERTIFICATES OF INSURANCE AT A $1,000,000 LIMIT?

Yes No

RECEIPTS / PAYROLL / DOLLAR VALUE INFO

Gross receipts for the past 3 years and the next 12 months

(3RD YR PRIOR) $

(2ND YR PRIOR) $

(LAST 12 MTHS) $

(NEXT 12 MTHS) $

NUMBER OF OWNERS/OFFICERS/PARTNERS ACTIVE AT THE JOB SITE OR SUPERVISING

PAYROLL OF EMPLOYEES EXCLUDING OWNERS, OFFICERS, PARTNERS & CLERICAL ($)

DOLLAR VALUE OF AVERAGE JOB COMPLETED INCL. ALL MATERIALS, LAB OR & EQUIPMENT ($)

DESCRIBE ANY PROJECTS) UNDERWAY OR PLANNED FOR THE NEXT YEAR, INCLUDING VALUES

Miscellaneous and Legal Info

HAVE YOU EVER PERFORMED GROUND UP CONSTRUCTION INVOLVING CONDOMINIUMS, TOWNHOUSES, APARTMENTS, OR SINGLE FAMILY TRACT DEVELOPMENTS OF TWO (2) OR MORE?

Yes No

HAVE YOU EVER BEEN NAMED IN LITIGATION REGARDING FAULTY CONSTRUCTION?

Yes No

ARE THERE ANY CLAIMS OR LEGAL ACTIONS PENDING?

Yes No

DO ANY OF THE ENTITIES NAMED IN THE APPLICATION HAVE KNOWLEDGE OF ANY PRE-EXISTING ACT, OMISSION, EVENT, CONDITION OR DAMAGES TO ANY PERSON OR PROPERTY THAT MAY POTENTIALLY GIVE RISE TO ANY FUTURE CLAIM OR LEGAL ACTION AGAINST ANY SUCH ENTITY?

Yes No

CLAIMS HISTORY

Enter all claims or occurrences that may give rise to claims for the prior 3 years. This information is kept strictly confidential

Claim #1

CLAIM STATUS

Closed Open

DATE OF OCCURRENCE

DATE OF CLAIM

TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM

AMOUNT PAID ON YOUR BEHALF

AMOUNT RESERVED ON BEHALF

Claim #2

CLAIM STATUS

Closed Open

DATE OF OCCURRENCE

DATE OF CLAIM

TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM

AMOUNT PAID ON YOUR BEHALF

AMOUNT RESERVED ON BEHALF

ADDITIONAL COMMENTS

PLEASE GIVE ANY ADDITIONAL COMMENTS YOU FEEL APPROPRIATEFOR THIS QUOTATION.

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Locations

Main Office
ISU-Great Northern Insurance Agency 39850 Van Dyke Ave Sterling Heights , MI 48313
Phone:248-856-9000
Fax:248-856-9001
California Office
Kevin Lam 1900 Camden Ave San Jose, CA 95124
Phone:(408) 444-5196
Fax:(877) 275-1639
Ann Arbor Office
Kristine Reed PO Box 3306 Ann Arbor, MI 48106
Phone:(734)945-0027
Phone2:(248)856-9000
Fax:(248)856-9001

Great Northern Insurance Agency Our Dedication Ensures Your Satisfaction

General Liability Quote

Our process is transparent

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Great Northern Insurance Agency
Our Dedication Ensures Your Satisfaction