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General Liability Online Application

Please fill out the form below and we will contact you shortly

Quotation Purposes Only: Form Submittal does not bind coverage.
Program Director: Dave Wicker
* Denotes Required Field
Desired Effective Date:
Today's Date:
Applicant Name: *
Name of Insured: *
Business Name: *
Address: *
City: *
State: *
Zip: *
Is your physical address different than above?   
Email: *
Phone: *
Website Address:
Do you own any other business?  
Year Business Started: *
Owner's Years of Experience:
Number of Employees, including owners
Do employees use personal autos for course of business?   
FEIN Number (if INC. or LLC.) / SSN (if sole prop, or DBA): *
Estimated Receipts for next 12 months:
Office Information
Type of Office:   
Building Construction:
Building Square Feet:
Office Square Feet:
Year Built:
How many stories:
Does the property have sprinklers?   
Is the property alarmed?   
Is vehicle insured in company name?   
Estimated Business / Office equipment and tools value:
Will you need waiver of subrogation coverage?  
How many years of management experience does the management team have in this industry?
Do you currently have general liability insurance?   
Do you currently have professional liability insurance / errors & omissions?   
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?   
Has insured been non-renewed or cancelled during the past three years for other than non-payment of premium?   
During the last ten years, has any applicant been convicted on any degree of the crime of arson?   
Are there any additional interests, interested parties, mortgagees or loss payees to be added with this transaction?   
Are there any other business interests or activities of the named insured that are not identified or scheduled on this policy?   
Does the applicant have any subsidiaries or is the applicant a subsidiary of another entity?   
Is the business an employee leasing, labor leasing, labor contractor, PEO, temporary worker staffing or employment agency firm?   
Does the insured own any autos that are titled in the name of the business?   
Are non-owned autos (i.e. employee's personal autos) used either daily or weekly in the course of the insured's business?   
Are any operations open 24 hours a day?   

Quick Contact


David Wicker
Program Director
Direct: 315-552-5334 direct
Cell: 315-877-3930
Fax: 315-234-7508
Email: dwicker@chinsurance.cc

Caroline Touse
Program Manager
Direct: 315-234-7500 x5342
Fax: 315-234-7508
Email: ctouse@chinsurance.cc


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Contact Information
100 S. Salina St., Suite 370
Syracuse, NY 13202
Phone: (315) 234-7500
Fax: (315) 234-7508
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