Fillable General Liability Application (RT Specialty)

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General Liability Application (RT Specialty)

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The General Liability Application (RT Specialty) form is 3 pages long and contains:

  • 2 signatures
  • 18 check-boxes
  • 81 other fields

Country of origin: US
File type: PDF

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H
ome Office:
One Nationwide Plaza, Columbus, Ohio 43215
Administrative Office:
8877 North Gainey Center Drive • Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
A Stock Company
General Liability Application
APPLICANT’S NAME AGENCY
ADDRESS AGENT NAME
ADDRESS
PROPOSED EFFECTIVE DATE: From To
12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”
LIMITS OF LIABILITY REQUESTED
PREMIUM
COVERAGE EACH OCCURRENCE AGGREGATE
BODILY INJURY $
,000 $
,000 $
PROPERTY DAMAGE $
,000 $
,000 $
COMBINED SINGLE LIMIT $
,000 $
,000 $
PREMISES MEDICAL
PAYMENTS
EACH PERSON EACH ACCIDENT
$
$
,000 $
,000
PERSONAL INJURY A B C
PARTICIPATION %
DELETE EXCLUSION C
AGGREGATE
$
$ ,000
OTHER COVERAGE AND/OR ENDORSEMENTS
$
TOTAL
$
1. Indicate Coverages Desired:
Completed Operations Owners & Contractors Protective
Comprehensive General Owners, Landlords and Tenants
Contractual Personal Injury
Manufacturers & Contractors Products
Premises Medical Payments
2. Describe all business operations conducted by applicant:
3. Locations, age and construction of all premises owned, rented, or controlled by applicant (attach schedule if neces-
sary:
GLS-APP-1 (11-06) Page 1 of 3
Submit Application
4. Interest of applicant in such premises: Owner General Lessee Tenant
Part Occupied by the applicant: Entire Portion None
5. Number of years in business:
6. Does applicant have a parking lot? ............................................................................................................. Yes No
If so, state area:
If applicant charges for the use of the parking lot, indicate gross receipts from this operation: $
Indicate type of surface: Gravel Black Top Concrete
Is the lot lighted? .......................................................................................................................................... Yes No
7. Does risk store L.P.G. flammable liquids, ammunition or explosives on the premises? ............................. Yes No
If so, type and quantity stored:
8. Does risk lend, lease, or rent any equipment to others? ............................................................................. Yes No
If so, state the type of equipment involved and the gross receipts derived therefrom:
9. Does applicant subcontract work? ............................................................................................................... Yes No
If so, state type:
Are Certificates of Insurance required from all subcontractors? ................................................................. Yes No
10. During the past three years, has any company ever canceled, declined or refused to issue similar
insurance to the applicant? ..........................................................................................................................
Yes No
If so, explain:
11. List details and amounts paid or in reserve for all claims which occurred during the last three years:
12. PRIOR CARRIER NAME AND POLICY NUMBER:
13.
Loc.
No.
DESCRIPTION OF EXPOSURES Premium Basis
Premises—Operations (Give complete description.
Include parking lot areas for
all stores):
(a) Area (sq. ft) (b) Frontage (c) Remuneration
(d) Receipts
Escalators—Number of Landings
(Number)
Elevators
Owners’ or Contractors’ Protection
(Independent Contractors—Let or Sublet Work)
(a) Cost (total) $
Contractual—SUBMIT COPY
(a) Cost $
(b) Number of Contracts
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
GLS-APP-1 (11-06) Page 2 of 3
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information, or conceals for the purpose of misleading, in-
formation concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by active owner, partner or executive officer)
PRODUCER’S SIGNATURE: _______________________________________________________________ DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
GLS-APP-1 (11-06) Page 3 of 3
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General Liability Application (RT Specialty)

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Completed 30 July 2020

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