Commercial General Liability Prefer to fill out by hand? Click here to download a printable version Entity Name DBA PhoneEmail Website Insured Form of Business Individual Corporation LLC Partnership Other Number of PartnersTax ID Number Date Established Month Day Year Years Experienced Mailing/billing address City State ZIP Code ParishSelect...Acadia ParishAllen ParishAscension ParishAssumption ParishAvoyelles ParishBeauregard ParishBienville ParishBossier ParishCaddo ParishCalcasieu ParishCaldwell ParishCameron ParishCatahoula ParishClaiborne ParishConcordia ParishDeSoto ParishEast Baton Rouge ParishEast Carroll ParishEast Feliciana ParishEvangeline ParishFranklin ParishGrant ParishIberia ParishIberville ParishJackson ParishJefferson ParishJefferson Davis ParishLafayette ParishLafourche ParishLaSalle ParishLincoln ParishLivingston ParishMadison ParishMorehouse ParishNatchitoches ParishOrleans ParishOuachita ParishPlaquemines ParishPointe Coupee ParishRapides ParishRed River ParishRichland ParishSabine ParishSt. Bernard ParishSt. Charles ParishSt. Helena ParishSt. James ParishSt. John the Baptist ParishSt. Landry ParishSt. Martin ParishSt. Mary ParishSt. Tammany ParishTangipahoa ParishTensas ParishTerrebonne ParishUnion ParishVermillion ParishVernon ParishWashington ParishWebster ParishWest Baton Rouge ParishWest Carroll ParishWest Feliciana ParishWinn ParishOwner and Percent Owned PhoneDate of BIrth Month Day Year Social Security Number Owner and Percent Owned PhoneDate of BIrth Month Day Year Social Security Number Detailed description of business operationsLicenses HeldLicense Numbers Add RemoveGross Annual Sales Volume% New Construction% Residential% Commercial % Remodel/Renovation Prior Liability Coverage? Yes No Carrier Limit Any losses in the last 5 years? Yes No Loss HistoryDate of LossLoss Description Add Remove% Subs/Contract Workers Used Any Uninsured Subs Used? Yes No CommentsThis field is for validation purposes and should be left unchanged. Δ
