General Liability Questionnaire

General Liability
Questionnaire

C Wong Insurance Agency
license# 0B96625
(800) 388-0074
FAX: 707-644-6272

Name:

Business name:

Address:

City:

State:

Zip Code:

FAX:

Telephone #

E-Mail:

Years in Business?

Years experience?

Contractor's License #

Type of business:

Sole Proprietor

Partnership:

# of active partners:

Corporation:

# of active corporate officers:

Current Carrier:

Expiration date:

Liability Limits:

Years of continuous coverage?

Have you had any claims or losses in the past 5 years?

Yes

Description of Operations:

Employee Payroll per year:

Gross Receipts per year

Number of employees active in field

Full time:

Part time:

Amount of Work Sub-contracted?

Dollar amount:

or Percent: (%)

Trades Subbed Out:

Percent of Work that is:

Residential:

Commercial:

Industrial:

New Construction:

Remodeling:

Repair/Service:

Is any New construction for Condo's, Tract Homes, Apartments or Townhouses?

Any work for Home Owners Associations?

Home Warranty Companies?

Warranty work on New Tracts?

Any Water / Fire / Flood Repair work?

Any Playground / Grandstand / Bleacher Work?

Any work in Hospitals / Airports / Refineries / Computer Clean Rooms?

General Contractors:

Skylight work

Retaining Walls

Structural Work in SF?

Earthquake Retrofit?

Electrical Contractors:

Solar Work?

Fiber Optics

Co-Axial install (outside premises)

Satellite Dishes

Plumbing Contractors:

Sewers

Water Mains

Radiant Heating Systems

Septic Systems

Landscape Contractors:

Sprinklers

Retaining Walls

Tree Stump Removal

Tree Trimming

Painting Contractors:

Exterior stories # of Floors:

Waterproofing?

Exterior Spray Painting

Will you require any particular endorsements
or special wording in the policy?

Additional comments or information you wish to provide: