GENERAL LIABILITY APPLICATION SUPPLEMENT
This application must be attached to the Public Transportation Application.
Name
Submission/Policy Number:
Proposed Effective Dates: FROM:
TO:
PRIOR CARRIER AND LOSS INFORMATION
Location
#
Location Description
Location
Type*
Territory
Square Feet
PUBLIC TRANSPORTATION
Date
Amount
Description of Loss
(Use separate sheet if necessary)
T-402 (6/14)
ISO
Area
LIMITS
Excluded
100,000
5,000
LOCATION INFORMATION
TOTAL
* OF = Office GA = Garage OT = Other
UNDERWRITING INFORMATION
Yes
No
No
Yes
© 2014 The Travelers Indemnity Company. All rights reserved.
Has insurance of this type been canceled, refused, or nonrenewed by any company during the past 3 years?
(Missouri Applicants - Do not answer this question.)
Yes No If yes, give name of company, date, amount and description of loss.
General Aggregate
Products-Completed Operations Aggregate
Personal & Advertising Injury
Each Occurrence
Damage to Premises Rented to You
Medical Expense (any one person)
$
$
$
$
$
1.
Fully describe the insured's operation.
2.
Describe drop-off procedures and rules.
Are drop-off procedures in writing?
3.
Does the insured engage in:
a.
Storage of goods of others (warehousing)
b.
Repair of vehicles of others
c.
Storage of vehicles of others
d.
Space leased to others
e.
Sale of fuel or other products
f.
Providing alcoholic beverages for clients
g.
Any sporting or social events sponsored
h.
Any other business operations
Explain all YES answers.
1
2
3
4
5
