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AmTrust International Underwriters Ltd

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Wesco Insurance Company
Security National Insurance Company

Contractors
General Liability
Application

Agency Information
Agency Business Name: _________________________________________________________________.
Agency Contact First & Last: _____________________________________________________________.
Agency Contact Number: ________________________________________________________________.
Agency Email Address: _________________________________________________________________.
Agency Mailing Address: ________________________________________________________________.
Applicant Information
Applicant Business Name: _______________________________________________________________.
Applicant Owner(s) First & Last Name: _____________________________________________________.
Applicant Phone Number: ________________________________________________________________.
Applicant E-mail Address: _______________________________________________________________.
Applicant Mailing Address: ______________________________________________________________.
Applicant Business Address: ______________________________________________________________.
Applicant License Number (or pending): ____________________________________________________.
Applicant Entity Business Type: [_] Sole Proprietor or Individual
[_] Partnership
[_] Trust
[_] Limited Partnership
[_] Corporation
[_] Joint Venture
[_] LLC
[_] LLP
General Liability Rating Criteria
Limit of Insurance: [_] $300,000/$300,000/$300,000
[_] $500,000/$1,000,000/$1,000,000
[_] $1,000,000/$2,000,000/$1,000,000
Deductible: [X] $500

[_] $500,000/$500,000/$500,000
[_] $1,000,000/$1,000,000/$1,000,000
[_] $1,000,000/$2,000,000/$2,000,000

Estimated Yearly Owner Payroll for this policy:
Estimated Yearly Employee Payroll for this policy:
Estimated Yearly Subcontracting Costs for this policy:
Estimated Yearly Gross Receipts for the year:
Total Number of Owners for this policy:
Total Number of Part Time Non-Clerical Employees for this policy:
Total Number of Full Time Non-Clerical Employees for this policy:

[$_________________]
[$_________________]
[$_________________]
[$_________________]
[#___________]
[#___________]
[#___________]

Classification: (Must equal 100% and limited to 4 Contractor Trades per policy)
Contractor Trade #1: ______________________________________________________.
Contractor Trade #2: ______________________________________________________.
Contractor Trade #3: ______________________________________________________.
Contractor Trade #4: ______________________________________________________.

[__________%]
[__________%]
[__________%]
[__________%]

Business Experience / Insurance History:
[_] New In Business
[_] Operating Business Without Prior Insurance
[_] 1-59 days without GL coverage
[_] 60+ days lapse in GL coverage
[_] 1 Year in business with no lapse in GL coverage and no losses
[_] 2 Years in business with no lapse in GL coverage and no losses
[_] 3 Years in business with no lapse in GL coverage and no losses
[_] 4 Years (or more) in business with no lapse in GL coverage and no losses
[_] Other - claim in the past year
Total Number Of Years In Business:
Total Number Of Years Of Experience:

[#___________]
[#___________]

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