CPL APPLICATION
(Comprehensive Personal Liability)
First Name:
MI:
Last Name:
Mailing Street Address
*
:
Apartment Number/ Unit
P.O. Box
City:
State:
California
Zip Code:
Contact Number:
Alternate Contact Number:
Fax Telephone:
Date of Birth:
Martial Status:
Occupation:
Employer's Name
Email Address:
Location address of premises
Proposed Effective Date
List all owned or occupied residences, buildings or vacant land. Farm property is not eligible for this coverage:
Address
# of Units
Occupancy-Primary/Rental/Vacant
1.
2.
3.
4.
Underwriting Questions
1. Is there a Spa or swimming pool on the premises?
NO
YES
Is it fenced?
YES
NO - not eligible
Is there a slide or diving board?
NO
YES - not eligible
Is the pool/spa currently filled?
YES
NO - not eligible
2. Do you own or lease any boats?
NO
YES - The policy may not provide coverage and you should ask your agent about securing boat liability coverage.
3. Do you own or board any animals?
NO
YES- list all types and breeds
4. Any unusual exposures on the premises, i.e. broken steps or handrails, lifter in the yard, etc.
NO
YES - explain. Previous Insurance Company, Policy Number, Expiration
5. Is there any business conducted on the premises?
NO
YES - explain completely.
6. Do you employ any residence employees?
NO
YES
Number In-servants? Number Out-servants?
7. Do you have any non-owned property exceeding $1,000 in value in your care, custody or control?
NO
YES - Explain completely,
8.Have you had any liability losses in the past 5 years?
NO
YES - please provide complete details.
Date , Description of loss, Amount Paid
Requested Limit of Liability:
$100,000 or
$300,000 or
$500,000
Additional Comments:
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.